Nanny Fraser

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Pick-up and Drop-off

Schedule and Program Plan

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Parent Information

Child Information

Pick-up Authorization

Do Not Authorize for

Pick-up

Parent Agreement Contract

Download PDF Version

Additional Info

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C. Fraser © 2008, Fraser Service Group. All Rights Reserved.

Section 12 (a)

Do Not Authorize Form

If you have trouble printing this document under the current format, you can download the PDF version of the handbook here.

Child’s full name:__________________________

Name:		Known aliases (or other names that the child might refer to):
Relation to your child or family:
Physical description:
Instructions should contact be attempted:
Additional details or concerns (if you wish to share the individual’s address, the information can be shared with authorities should an emergency arise):
Photograph provided? Yes or No	A photograph can help identify the unauthorized individual quickly, which may help to prevent potential conflict. In case of emergency, the photograph will shared with authorities.

(Additional forms can be provided if needed)

I, ____________________________________ prohibit the above mentioned individual from retrieving my child from daycare. Furthermore, I request that Christina Fraser follow any directions listed above in the event this unauthorized retrieval is attempted.

I reserve the right to retract this request at any time, provided this retraction is given in writing and no less than two days before retrieval is attempted.

Signature: __________________________

Date:__________________________