# Temporary Pickup Authorization Form

**School name:** ________________________________

**Student name:** _______________________________

**Class / grade:** ______________________________

**Parent / guardian name:** ______________________

**Parent / guardian phone:** _____________________

## Temporary authorized person

**Full name:** __________________________________

**Relationship to student:** _____________________

**Phone:** ______________________________________

**Email:** ______________________________________

**ID type / number, if required:** ______________________________________

## School-side temporary pickup notes

Use this area to record the temporary pickup details for staff review. These notes are not automatically enforced by the digital system. Staff must verify them manually according to School procedure.

**Date(s) requested:** __________________________

**Expected pickup / drop-off time:** ______________________

**Reason for temporary authorization:** ________________________________________________

## Permission granted

I authorize the person named above to pick up or drop off the student for the temporary situation described on this form, subject to School verification and approval. This authorization does not replace any regular pickup authorization unless the School confirms otherwise.

The School may record this temporary authorization in its digital system and may maintain a check-in, check-out, confirmation, or audit record related to this pickup or drop-off.

## Parent / guardian acknowledgement

I understand that:

- The School may require identification before releasing the student
- The School may deny release if authorization cannot be verified
- The School must remove or disregard this temporary authorization when it is no longer valid
- I must contact the School if plans change

**Parent / guardian signature:** ______________________________

**Printed name:** ____________________________________________

**Date:** ____________________________________________________

## School use only

Approved by: ______________________________

Date approved: ____________________________

Entered in digital system by: ______________________________

Closed / removed by: ______________________

Notes: _______________________________________________________

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**Template note:** This sample is provided for general onboarding and operational support. Schools should review and adapt it to their own policies, legal requirements, and local regulations before use.