Bear River Recreation and Parks District

Print, Fill Out and Mail to: BRRPD Summer Daycare Camp 10042 Wolf Rd., Suite B, #11  Grass Valley, CA  95949 OR Drop in office Mail Slot at: 10516 Combie Rd., Auburn, CA 95602 In the Combie Plaza near Paws and Claws

After-School Childcare - 08/09

Child Pick-Up Authorization Form

I hereby authorize the following people to pick up my child, ________________________________,
from the after-school daycare program and leave the facility. I understand that for the protection of
my child, daycare staff may require that identification be presented. I also understand that no other
person will be allowed to take my child from the daycare facility without my written permission.

In the event of an emergency, if I can not be contacted, the following list can also be used.

	Signiture of Parent / Guardian: ________________________________ Printed Name: ________________________________ Phone: ________________________________ 2nd Phone: ________________________________ e-mail: ________________________________
	Name: Relationship: Contact Phone Numbers: 1. _____________________________ _____________ _________________________ Home _________________________ Cell _________________________ Work . 2. _____________________________ _____________ _________________________ Home _________________________ Cell _________________________ Work . 3. _____________________________ _____________ _________________________ Home _________________________ Cell _________________________ Work . 4. _____________________________ _____________ _________________________ Home _________________________ Cell _________________________ Work . 5. _____________________________ _____________ _________________________ Home _________________________ Cell _________________________ Work

---

Updated August, 2008