Authorization for Release Form

Hosanna Lutheran Childhood Center
Authorization for Release

Parent's Name*
First Last
Email*
Enter Email Confirm Email
Child's Name*
First Last
Child's Birthdate*
Month
Day
Year
Class Child Is Enrolled In*
The following people have authorization to pick up my child from Hosanna Lutheran Childhood Center
1. Name
First Last
Phone
2. Name
First Last
Phone
3. Name
First Last
Phone
4. Name
First Last
Phone
I understand that if changes need to be made that it is my responsibility to contact the preschool administrator.
Parent/Guardian Signature (Typed)*
First Last