Authorized Pickup Form

Version 2026.1 · Effective August 23, 2026

Child

Child’s full name: ______________________________________________
Date of birth: ____________________

Parents/guardians

Name	Relationship	Phone	May pick up?
__________________	__________________	__________________	☐ Yes ☐ No
__________________	__________________	__________________	☐ Yes ☐ No

Authorized pickup persons

Full name	Relationship	Phone	Identification notes
__________________	__________________	__________________	__________________
__________________	__________________	__________________	__________________
__________________	__________________	__________________	__________________

Only persons listed in writing may pick up the child, subject to applicable legal restrictions. Teida’s Tots may request identification before releasing a child.

Restrictions and changes

☐ There are custody or court-order restrictions. A current copy must be provided to Teida’s Tots.

☐ There are no known custody or pickup restrictions.

Parents must notify Teida’s Tots in advance of changes whenever possible. A verbal or text request may be accepted only according to the provider’s final pickup procedure.

Parent acknowledgment

I confirm that the information above is accurate and authorize the listed persons to pick up my child, subject to the provider’s policies and applicable law.

Parent/guardian signature: ______________________________________
Printed name: _________________________________________________
Date: ____________________

Provider signature: ____________________________________________
Date: ____________________