Camp Allegheny Day Camp

Pick Up and Release Form

The following persons are authorized to pick up _________________________

from Camp Allegheny. (Child’s Name)

Please make sure all adults who have permission to pick-up your child is listed as their (your) name appears on their (your) driver’s license. Mom’s and Dad’s please make sure both parent’s names' are listed as well if applicable.

Name Address Phone#

1._______________________________________________________________

2._______________________________________________________________

3._______________________________________________________________

4._______________________________________________________________

I understand that ONLY those persons listed above will be authorized to pick up my child.

Signature:____________________________________Date:________________

Name:___________________________________________________________

(please print)

Please plan on picking your child up between 4:30pm and 6:00pm

A late fee of $5.00 every 15-minute period per child will be charged for late pick-ups.