Beaufort Jasper EOC Head Start

Verification of Responsible Receiver

ACCORDING TO THE BJEOC HEAD START POLICY, CHILDREN MUST BE RELEASED TO ONLY INDIVIDUALS AUTHORIZED TO PICK THEM UP. ONLY PERSONS LISTED BELOW WILL BE PERMITTED TO PICK UP YOUR CHILD. ALL PERSONS MUST HAVE AND SHOW THEIR PICTURE ID. MAKE SURE YOU LIST ALL ADULTS EVEN IF YOU RESIDE IN THE SAME HOUSEHOLD. PERSONS MUST BE 18 YEARS OR OLDER

THE FOLLOWING ADULTS ARE AUTHORIZED TO PICK UP MY CHILD FROM SCHOOL

Child's Last Name: *
Child's Middle Name:
Child's First Name: *
What program option are you registering for? *

Center: *
Mobile Number
Work Phone
Home Phone
Address
City
State
Zip Code
Mobile Number
Work Phone
Home Phone
Address
City
State
Zip Code

PERSON(S) OTHER THAN PARENT/GUARDIAN AUTHORIZED TO PICK UP CHILD

Name of Authorized Person Phone (Cell/Home/Work) Relationship to Child
Family code word(S)

I authorize BJEOC Head Start to release my child to any person listed above. I understand all “Authorized Pick-Up Person” must be at least 18 years old, will be asked to provide photo ID, and the family code word(s). I agree that this authorization shall remain valid for the duration of my child’s enrollment in Head Start until changed in writing by completing the required form, in person, at my child’s Head Start Center.

Parent/Guardian Name:
Date:
I confirm that I have read and understand this form. *

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Parent Signature
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