After School Pick-Up Authorization Form

Revolution Martial Arts - Mission

To better ensure the safety of your child, we are asking that all parent/guardians fill out this Pick-Up Authorization Form. Please complete the form at the bottom of this page and return it along with your registration form. If this form is not thorough and complete, we Revolution Martial Arts will not release your child to anyone who you have not included on this Pick-up Authorization Form. All of the precautions for releasing students are to insure the safety of your child and are not meant to cause intentional inconvenience for parents. We very much appreciate your understanding and cooperation with our policies regarding student pick-up.

If the pick-up person is someone not on your list, we will require a written note be sent to our receptionist before the end of your child's class with your signature authorizing the non-listed person to pick up. A follow up phone call will be made to parents confirming the written authorization. We cannot accept phone call pick-up changes if it will be someone not on your authorized list. You will be notified immediately if someone NOT on your list comes to pick up your child and we have not received a written note with your authorization. Picture I.D. is required for all individuals picking up a child. Please notify the people on your list that photo I.D. will be requested by the Program Manager prior to releasing your child. This also applies to anyone you authorize in a written note to pick up your child. If a spouse or child of a person listed below comes in to pick up your child, we WILL NOT release the child to that person. Your child will only be released to the person named on your list and after verifying the person with their picture I.D. We know that emergencies and unusual

situations happen, however we ask that you please try to restrict the people who pick up your child to the ones on the Pick-up Authorization Form. If changes need to be made to this list during the course of the school year, please speak to the Program Manager to complete a new form.

Student Full Name

Parent/Guardian Full Name

Primary Phone Number

Secondary Phone Number

I authorize the persons listed below to pick up my child from Revolution Martial Arts. Please include names of both parents or guardians on this list.

Please Write: Full Name Relationship to Student Phone Number

Date

By signing below, I verify that I have read and agree to the Student Pick-up policies described on the Pick-up Authorization Form, and authorize Revolution Martial Arts to release my child to the above listed persons.

Parent/Guardian Signature