Name: Relation: Cell: Work: Home: Name: Relation: Cell: Work: Home: Name: Relation: Cell: Work: Home: Name: Relation: Cell: Work: Home: Name: Relation: Cell: Work: Home: Please list any person(s) NOT AUTHORIZED to pick up: ___________________________________________________________________ ___________________________________________________ Name and phone number of the first person to be called in case of an emergency: __________________________________________________________________ Custody: Who has custody of my child? ___Mother ___Father ___Other: ________ Helpful information about the child such as anxieties or fears? 5 Recording Authorization Form BRICKS Early Learning Center takes photographs and videos of children enrolled at its center on a regular basis for business purposes. BRICKS Early Learning Center retains all rights, title, and interest in these materials and may use and disseminate them in the class Shutterfly accounts. BRICKS Early Learning Center takes care that any use, display, or that disseminate all photographs or videos of
Name: Relation: Cell: Work: Home: Name: Relation: Cell: Work: Home: Name: Relation: Cell: Work: Home: Name: Relation: Cell: Work: Home: Name: Relation: Cell: Work: Home: Please list any person(s) NOT AUTHORIZED to pick up: Name and phone number of the first person to be called in case of an emergency: __________________________________________________________________ Custody: Who has custody of my child? ___Mother ___Father ___Other: ________ Helpful information about the child such as anxieties or fears? 5 Recording Authorization Form BRICKS Early Learning Center takes photographs and videos of children enrolled at its center on a regular basis for business purposes. BRICKS Early Learning Center retains all rights, title, and interest in these materials and may use and disseminate them in the class Shutterfly accounts. BRICKS Early Learning Center takes care that any use, display, or that disseminate all photographs or videos of ___________________________________________________________________ ___________________________________________________
bricks_elc_application_.docx