Free Daycare Form

Authorized Pickup Form

List the people permitted to pick up a child from care. Information entered here is not saved to CubbyTrack.

Pickup authorization and identification requirements vary by childcare program and jurisdiction. Follow your center policies and applicable licensing requirements.

Authorized Pickup Form

Childcare Pickup Authorization

Child Information

Child's Full NameDate of BirthChildcare CenterClassroom / Group

Parent / Guardian

Parent / Guardian NamePrimary PhoneAlternate Phone

Pickup Restrictions / Special Instructions

I authorize the people listed above to pick up my child from the childcare program. I will notify the program when this authorization changes.

Parent / Guardian Signature

Date

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Authorized Pickup Form

Authorized Pickup Form

Child Information

Parent / Guardian

People Authorized to Pick Up This Child

Pickup Restrictions / Special Instructions