I/We ________________________________ give Pamela Ball of Pam’s Play Place and Preschool permission to release my/our child to the following person(s):

Name __________________________________________ Phone_____________________________

Address ________________________________________ Relationship to child ________________

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Name __________________________________________ Phone_____________________________

Address ________________________________________ Relationship to child ________________

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Name __________________________________________ Phone_____________________________

Address ________________________________________ Relationship to child ________________

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Name __________________________________________ Phone_____________________________

Address ________________________________________ Relationship to child ________________

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Name __________________________________________ Phone_____________________________

Address ________________________________________ Relationship to child ________________

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I/We ________________________________ certify that all of the information given on this form is correct and accurate to the best of my/our knowledge. I/We ___________________________ promise that I/We _________________________________ will notify the provider, if any or all of this information changes.

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I/We ________________________________ understand that if Pamela Ball has not met the person picking up my/our child ______________________________ she will ask for a photo I.D. before my/our child may be released. I/We _____________________________ must notify Pamela Ball in advance when alternate arrangements are made for my/our child ______________ to be picked up by a person designated on this list.

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