DARTMOUTH GIRL POWER RELEASE FORM

As a safety precaution, no child will be released to anyone who is not listed on the form below. Please include parents on the list. Thank You!

Child’s Name __________________________

The following adults have my permission to pick-up my child following group time:

ALL INFORMATION IS STRICTLY CONFIDENTIAL.

_____________________________________________ ______________________

Parent/Guardian Signature Date

_________________________________________________________________________________

Address

______________________________ ______________________________ __________________

Home phone Work phone Cell phone

PLEASE RETURN THIS COMPLETED FORM TO KEVIN LEE, YOUTH ADVOCATE. Thank You!