Child Pick-up Authorization Form
The safety of your child is our number one priority. Please list any person other than the primary caregiver indicated below who is authorized to pick up your child. For the safety of your child, Empowered Sports & Fitness will not release your child to any person who has not been indicated on this form. If changes need to be made at any time, please contact us. We appreciate your understanding and cooperation.
Child's Name
(Required)
First
Last
Date of Birth
(Required)
Month
Day
Year
Parent/Guardian
(Required)
Name
Phone Number
Add
Remove
I hereby give authorization for the following person(s) to pick up my child from Empowered Sports & Fitness Social Skills Group
Authorized Pickup
(Required)
Name
Relationship to Child
Phone Number
Add
Remove
