Persons Authorized to Pick Up Child

Parent/Guardian First Name:*
Parent/Guardian Last Name:*
Phone Number:*
Email Address:*
Child's Name:*
Date of Birth:*
MM slash DD slash YYYY
Therapy Day:
Therapy Time:
Please complete the following fields:
Name of Person Authorized to Pick Up Child Relationship to Child Cell Phone Number

Click (+) on the right to add rows.
Date
MM slash DD slash YYYY

Name of Person Authorized to Pick Up Child	Relationship to Child	Cell Phone Number