Parent Release Form 09 05
1
The participants will be released to those individuals listed below on this form. Ensure you list all people who are authorized to pick up your child(ren). Photo I.D. will be requested. T o ensure a safe exit for your child/ren from our program, or in case of an emergency situation, please provide the following information. Any change in the arrangement s must be done in advance. Indicate ONE preferred release type: My child/ren may leave the program unescorted at _____________________________ p.m. My child/ren will be picked up at the program. Form 2268 (09/05) Last Name - CHILD Home Phone Sex Male Female Business Phone Cell / Pager Last Name - PARENT/GUARDIAN Last Name - PARENT/GUARDIAN First Name - PARENT/GUARDIAN Home Phone Business Phone Cell / Pager First Name - PARENT/GUARDIAN Parent/Guardian Release Agreement The personal information on this form is collected under authority of Section 11 of the Municipal Act 2001, SO 2001, c. 25 and will be used to administer the City of Mississauga Recreation Camp Programs and specifically to ensure that children are not released to anyone other than those list- ed on the form. Questions about this collection should be directed to: Manager, Customer Service Centre, at 905-615-4100. Last Name First Name Last Name First Name Last Name First Name Last Name First Name Provide any information regarding the participant which may be helpful to staff. TWO THREE ONE Participant(s) Date TWO ONE Parent/Guardian Phone Phone Phone Phone First Name Last Name - CHILD Sex Male Female Provide any information regarding the participant which may be helpful to staff. First Name Last Name - CHILD Sex Male Female Provide any information regarding the participant which may be helpful to staff. First Name Print Name Signature
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Transcript of Parent Release Form 09 05
The participants will be released to those individuals listed below on this form. Ensure you list all people who areauthorized to pick up your child(ren). Photo I.D. will be requested.
To ensure a safe exit for your child/ren from our program, or in case of an emergency situation, please provide the following information. Any change in thearrangements must be done in advance.Indicate ONE preferred release type: My child/ren may leave the program unescorted at _____________________________ p.m.
My child/ren will be picked up at the program.
Form 2268 (09/05)
Last Name - CHILD
Home Phone
SexMaleFemale
Business Phone Cell / Pager
Last Name - PARENT/GUARDIAN
Last Name - PARENT/GUARDIAN
First Name - PARENT/GUARDIAN
Home Phone Business Phone Cell / Pager
First Name - PARENT/GUARDIAN
Parent/GuardianRelease Agreement
The personal information on this form is collected under authority of Section 11 of the MunicipalAct 2001, SO 2001, c. 25 and will be used to administer the City of Mississauga Recreation CampPrograms and specifically to ensure that children are not released to anyone other than those list-ed on the form. Questions about this collection should be directed to: Manager, Customer ServiceCentre, at 905-615-4100.
Last Name First Name
Last Name First Name
Last Name First Name
Last Name First Name
Provide any information regarding the participant which may be helpful to staff.
TWO
THR
EEO
NE
Participant(s)
Date
TWO
ON
E
Parent/Guardian
Phone
Phone
Phone
Phone
First Name
Last Name - CHILD
SexMaleFemale
Provide any information regarding the participant which may be helpful to staff.
First Name
Last Name - CHILD
SexMaleFemale
Provide any information regarding the participant which may be helpful to staff.
First Name
Print Name Signature
