Areas Marked With An * Must Be Filled Out - (Information is kept confidential)

Authorization Pick Up List

(Alternative Responsible Relatives or Friends within the area)

Other Children In The Household

Please Note: We Will Not Release Your Child To Anyone Who Is Not On The List

* Please let these people know they might be called in case of an emergency *

Child's Interests and Activities

Guidance and Behaviour

Health Information

Please place a checkmark for all immunizations received to date *