Authorized Pickup Person Form

School name: ________________________________

Student name: _______________________________

Class / grade: ______________________________

Parent / guardian name: ______________________

Parent / guardian phone: _____________________

Person being authorized

Full name: __________________________________

Relationship to student: _____________________

Phone: ______________________________________

Email: ______________________________________

Government ID type / number, if required by School policy: ______________________________

Permission granted

I authorize the person named above to pick up the student from the School according to School policy. I understand that the School may record this authorization in its digital school operations system and may use it to help staff identify and verify approved pickup persons.

School-side notes

Use this area for any internal instructions that staff must verify manually. These notes are not automatically enforced by the digital system.

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Parent / guardian acknowledgement

I understand that:

• The School may require identification before releasing the student
• The School may require digital confirmation before pickup is completed
• The authorized person must follow School arrival and dismissal procedures
• I must notify the School if this authorization changes or should be removed
• The School may deny release if authorization cannot be verified by staff

Parent / guardian signature: ______________________________

Printed name: ____________________________________________

Date: ____________________________________________________

Authorized person acknowledgement

I agree to follow the School's pickup and drop-off procedures. I will not share my account, QR code, password, or pickup authorization with another person.

Authorized person signature: ______________________________

Printed name: ____________________________________________

Date: ____________________________________________________

School use only

Approved by: ______________________________

Date approved: ____________________________

Entered in digital system by: ______________________________

Notes: _______________________________________________________

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.