I, ___________________________________, certify that I am the parent/legal guardian
                     (print your name)

authorized legal custody of ___________________________. The following adult(s) are
                                                 (print child’s name)

authorized by me to deliver/pick-up the child named above (print names below):



Name_____________________________________          Telephone Number___________________________________


Name_______________________________________________            Telephone Number_____________________________________________


Name_______________________________________________            Telephone Number_____________________________________________


Name_______________________________________________            Telephone Number_____________________________________________


Name_______________________________________________            Telephone Number_____________________________________________



___________________________________                __________________
     (signature of legal parent/guardian)                                (date)