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Student Pick-Up/ Release Authorization Form 19-20


Our first priority is the safety of all of our students, and we appreciate your help in bringing that about.

This form can be updated at any time. All updates should be submited to the Religous School office. If your family participates in a weekly carpool please ensure that all pick up drivers are listed. Please fill out this form by October 16, 2019.

Parent /Guardian #1

Parent /Guardian #2

Please list below all persons, besides parents/guardians, who are authorized to pick up your child from Temple Israel Religious School.

Note: For your child’s safety, all authorized persons may be asked for photo identification. Please inform the person on the list in advance on this precautionary measure. Persons may be added to the list or removed at any time, just inform office of any changes to this form.

NOTE: Your child WILL NOT be released to anyone who is not authorized. Authorization will be determined based on this form submitted by the parent. It is the parent’s responsibility to keep this information current. If you need to update/ add anyone to the list please call the RS office at 203-227-1656.

By signing here, I agree to the terms and conditions listed above regarding dismissal policy of Temple Israel.

By signing here, I agree to the terms and conditions listed above regarding dismissal policy of Temple Israel.

Account Details

Enter your name and e-mail address for your confirmation:

Payment Information

I would like to help offset Temple Israel's credit card processing fee with an additional 3% contribution.
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