St. Paul's
Day School

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Authorization Form

Authorizes SPDS staff to act on your behalf in specific situations (photo release, pickup authorization, etc).

Child's Name *

Program *

Parent Name *

Parent Email *

Phone *

Authorized Pickup #1 — Name *

Pickup #1 Phone *

Authorized Pickup #2 — Name

Pickup #2 Phone

Photo / Video Release *

I authorize photos and video for school use I do NOT authorize

Emergency Medical Care *

I authorize SPDS to seek emergency medical care for my child if I can't be reached I do NOT authorize

Parent/Guardian Signature *

By typing your name above, you agree to this form constituting your electronic signature.

Date *

St. Paul's Day School

A play-based preschool in Riverside, CT serving children 2–5. Because joy and kindness matter.

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200 Riverside Ave
Riverside, CT 06878
203.637.3503
info@spdsriverside.org

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