Alternate Caregiver Permission

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Authorization for Contact
I,  

(Name*)
  , authorize  

(Name*)

(Relationship*)
to act on my behalf regarding my child(ren) as specified below:
 
Child Information
Child's Name:*  
*
Child's Name:  
Child's Name:  
Child's Name:  
Child's Name:  
 
Authorize How to Contact



 
Authorization Signature
*
*
*
Today
 

Other Contact Number(s) For Parents:

Contact Numbers For Parents
1. Name:
Relationship:
Number:
2. Name:
Relationship:
Number:
3. Name:
Relationship:
Number:
4. Name:
Relationship:
Number: