EMERGENCY RELEASE AND AUTHORIZED ESCORTS FORM

CHILD'S INFORMATION
PARENT/GUARDIAN INFORMATION

Emergency Release Contacts:
Only individuals listed below will be considered as designated emergency release persons. Government issued ID will be required at time of pick up. All release persons must be above 16 years of age. Please submit a photo ID of all individuals listed below.


Non-emergency contact persons that are to be designated as release persons:
Only individuals listed below are authorized as designated release persons. Government issued ID will be required at time of pick up. All release persons must be above 16 years of age. Please submit a photo ID of all individuals listed below.

EMERGENCY RELEASE AND AUTHORIZED ESCORTS

Contact 1:

Authorization:

Contact 2:

Authorization:

Contact 3:

Authorization:

Contact 4:

Authorization:

Contact 5:

Authorization:

Contact 6:

Authorization:
EMERGENCY RELEASE AND AUTHORIZED ESCORTS

In accordance with the requirements of the New York City Health Code, Article 47, Section 47.57(h)(1) child care centers must obtain and maintain for every child a list of the name, relationship to child, address and contact information of every person the parent has authorized to escort a child from the child care service. The permittee shall not release any child to any individual who has not been identified by the parent(s)/guardian(s) as a person who is authorized to escort a child out of the service.

PHOTO CONSENT

STAY UPDATED

Tel: 718-240-9300   
Email: highdef_kids@hotmail.com

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