Little Flower - Day Care Center & Preparatory School in Brooklyn

Dear Parents,

In accordance with the Department of Health we must have on file the names, addresses and telephone numbers of the individuals permitted to drop off and collect your child/children from our school. If someone arrives to collect your child/children and we have not been introduced and their name is not in our file, we cannot allow your child to leave with them.

Please list below any person's name, address and telephone number, who might arrive to collect your child, so that we can avoid any embarrassment, inconvenience or heaven forbid tragedy.
Also, please call us if your child will not be in attendance.

If the persons you have designated are picking up for the first time, proper identification must be shown upon arrival.

Child's Name:
may be delivered or collected from school by the following adults:

1.

Mr.
Mrs.
Ms.
Miss
  Full Name:
Street address:
City:      State:      Zip Code:
Telephones:
Work: Home: Cell.:
2.

Mr.
Mrs.
Ms.
Miss
  Full Name:
Street address:
City:      State:      Zip Code:
Telephones:
Work: Home: Cell.:
3.

Mr.
Mrs.
Ms.
Miss
  Full Name:
Street address:
City:      State:      Zip Code:
Telephones:
Work: Home: Cell.:
4.

Mr.
Mrs.
Ms.
Miss
  Full Name:
Street address:
City:      State:      Zip Code:
Telephones:
Work: Home: Cell.:
5.

Mr.
Mrs.
Ms.
Miss
  Full Name:
Street address:
City:      State:      Zip Code:
Telephones:
Work: Home: Cell.:


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Parent/Guardian Signature                                         Date

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