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)

Parent/Guardian(Required)

Name

Phone Number

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