PSESD Early Learning Program Safe Arrival & Departure Tracking Form NOT Authorized” “Have October 2018 Center Director: If your organization does not allow children to be released to persons under the age of 18, email stating this. You do not need to complete this form or process. Subcontractor Name: Site Name: Classroom Session: Person(s) completing this form: ________________________ ________________________ _______________ ______________________________ Scan and email form after Fall Home Visits to: Center Director signature to verify that form is accurate and complete: ______________________________ ________________ Date . Form can be completed in handwriting or electronically List below parents/guardians who have NOT authorized their child to be released to persons under the age of 18 HS/EHS ONLY Enter date when new Enter date when date when Enter date when was stapled to the current Policy Change Notice Emergency verbal contact was Policy Change Safe Arrival & Departure Agreement and Emergency Treatment Treatment and made with Notice was and Consent Form to reflect the change. Note: If parent requests Consent Form is Child’s Name Parent/Guardian parent/guardian returned to add other authorized adults, you must start a new form. uploaded into C+ (keep original in file) CONTINUED… List below parents/guardians who have NOT authorized their child to be released to persons under the age of 18 HS/EHS ONLY
PSESD Early Learning Program Safe Arrival & Departure Tracking Form “Have NOT Authorized” October 2018 Center Director: If your organization does not allow children to be released to persons under the age of 18, email stating this. You do not need to complete this form or process. Subcontractor Name: ________________________ Site Name: ________________________ Classroom Session: _______________ Person(s) completing this form: ______________________________ Center Director signature to verify that form is accurate and complete: ______________________________ Date ________________ Scan and email form after Fall Home Visits to: . Form can be completed in handwriting or electronically List below parents/guardians who have NOT authorized their child to be released to persons under the age of 18 Child’s Name Parent/Guardian Enter date when verbal contact was made with parent/guardian date when Policy Change Notice was returned Enter date when Policy Change Notice was stapled to the current Safe Arrival & Departure Agreement and Emergency Treatment and Consent Form to reflect the change. Note: If parent requests to add other authorized adults, you must start a new form. HS/EHS ONLY Enter date when new Emergency Treatment and Consent Form is uploaded into C+ (keep original in file) CONTINUED… List below parents/guardians who have NOT authorized their child to be released to persons under the age of 18 HS/EHS ONLY