E3 Legacy Academy

Pick-Up Authorization

For the safety of your student, we will only release them to the individuals explicitly named and authorized below.

Pick-Up Authorization Form

Children Information

Please list all children enrolled at E3 Legacy Academy whom this authorization applies to:

Child's Full Name *

Grade *

Authorized Pick-Up Personnel

Only the following authorized persons may pick up my child from school:

Full Name *

Relationship to Child *

Primary Phone Number *

Alternate Phone Number

Family Circumstance Context

If you are divorced, we must know who has custody of your child. Please also indicate if any parent is NOT permitted to pick up your child. Provide any additional information that may be beneficial for your child's teacher to know regarding your family circumstance

Verification & Sign-off

Parent / Legal Guardian Printed Name *

Signature of Parent or Legal Guardian (Type Full Legal Name) *

Date Signed *

E3 Legacy Academy

Pick-Up Authorization

Pick-Up Authorization Form

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