2. Stevens Park Summer Recreation Program Pick Up Authorization Form

4. Camper’s Name:*

6. The following people (please include yourself) are authorized to pick up my child from the Stevens Park Summer Recreation Program. I understand my child will be allowed to leave with these individuals only. I also understand that the person picking up my child must do so in person. Children will not be allowed to leave without being signed out. Photo identification may be asked for.

8. Authorized Person’s Name (please print legibly)*
9. Relationship to Camper*
10. Phone Number(s)*
12. Authorized Person’s Name (please print legibly)
13. Relationship to Camper
14. Phone Number(s)
16. Authorized Person’s Name (please print legibly)
17. Relationship to Camper
18. Phone Number(s)
20. Authorized Person’s Name (please print legibly)
21. Relationship to Camper
22. Phone Number(s)
24. Authorized Person’s Name (please print legibly)
25. Relationship to Camper
26. Phone Number(s)
28. Name of person(s) NOT authorized to pick up my child:
30. Any custody issues we should be aware of:

    1. Yes
    2. No
32. Parent/Guardian Signature:*
33. Date*
    Date
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field