Permission To Leave Unaccompanied Form

permission to leave unaccompanied form

I (Parent/Guardian Name): *

First

Last

of (Child's Name): *

First

Middle

Last

Choose which program site you are giving authorization for your child to leave unaccompanied: *

My child will: *

Please specify:

Choose the frequency for this arrangement: *

Please specify date(s): *

Please specify the child’s destination upon leaving BGC Battlefords’ program site: *

Address Line 1

Address Line 2

City

State

Zip Code

Other:

Please specify location and address

My child is to leave BGC Battlefords' program site at: (time) *

Please provide the appropriate phone number you wish your child to call:

In an event that they will be picked up instead I will notify staff: *

Parent/Guardian Signature

Other special instructions: (ie: walking with another child):

Signature of Parent/Guardian *

Date / Time *