Student Release Form

Student Name:*
First Last
CSOA Program Name*
I want to…*
OPTION 1: PICK UP
For the safety of all of our participants, your child will not be released to anyone who does not appear on this list. Any changes to this list must be made in writing – please be sure to include yourself.

The following people are authorized to pick up my student from School of the Performing Arts Program(s) at Proctors Collaborative:
Authorized Pick-up #1
1. Full Name:*
1. Relation:*
1. Phone:*
Authorized Pick-up #2
2. Full Name:*
2. Relation:*
2. Phone:*
Authorized Pick-up #3
3. Full Name:
3. Relation:
3. Phone:
Authorized Pick-up #4
4. Full Name:
4. Relation:
4. Phone:
Authorized Pick-up #5
5. Full Name:
5. Relation:
5. Phone:
OPTION 2: Student Release
Check the below box to allow your student to release themselves for program(s).
Consent
By checking here, I understand that there will be no supervision upon my child leaving the classroom(s). I hereby waive any responsibility of the Proctors Collaborative staff. I affirm that I have responsibility to sign this consent.
Electronic Signature
By typing your name below and hitting Submit, you are agreeing to the above.
Signature*
First Last
Your Email*
Date*
MM slash DD slash YYYY
Phone*
Relationship to participant*

OPTION 1: PICK UP