# Authorized pickup form

Source: https://backpr.com/resources/templates/authorized-pickup-form. Last updated: 2026-10-19.

Lists every adult allowed to pick a child up and anyone who isn't, with the program's pickup rules. Keep a copy with each roster.

Free download: PDF https://backpr.com/media/templates/backpr-authorized-pickup-form.pdf · Word https://backpr.com/media/templates/backpr-authorized-pickup-form.docx · Spanish PDF https://backpr.com/media/templates/backpr-authorized-pickup-form-es.pdf

> Our pickup rules: we release children only to their parents or guardians and the adults listed on this form. Staff check photo ID whenever they don't know the adult. To add someone, a parent or guardian must update this form in writing before pickup.

**Child**
- Full name: ______
- Program and days: ______

**Adults allowed to pick up this child**
- Name, relationship, phone: ______
- Name, relationship, phone: ______
- Name, relationship, phone: ______
- Name, relationship, phone: ______

**Adults NOT allowed to pick up this child**
If this person is the child's parent or legal guardian, attach a copy of the court order (such as a custody or protective order). Without one, we may not be able to refuse pickup by a parent or guardian.
- Name and description (attach a photo if you have one): ______
- Name and description: ______

**Late pickup (filled in by the program)**
- Closing time: ______
- Late pickup policy and fee, if any: ______

**Parent or guardian**
- Parent or guardian's printed name: ______
- I authorize the adults listed under "Adults allowed to pick up this child" to pick up my child. Parent or guardian signature: ______
- Date: ______

### How to use it
- Keep a current copy with each day's roster, and check ID whenever staff don't know the adult.
- Ask families to update the form in writing when anything changes, and date every update.
- If a parent asks you to keep the other parent away, ask for a copy of the court order.
- Check your state's licensing rules on pickup and release.

**Can we refuse to release a child to a parent?**
Generally only if there's a court order that limits that parent's access. Without one, you may not be able to refuse. Ask for a copy of the order and talk to a lawyer if you're unsure.

**How often should families update their pickup list?**
At every registration, and any time something changes. Ask for changes in writing before pickup, not at the door.

Free to use and change, but not legal or medical advice. Check your state's licensing rules and your insurer's requirements, and have a lawyer review any consent or waiver language.