EmailMeForm
Authorisation Form - Single Use
This form should be used to provide permision for your child to be collected by a previously unauthorised person. THIS FORM IS FOR SINGLE USE ONLY AND CAN ONLY BE USED ON THE DATE LISTED. If you wish to provide ongoing authorisation please use the ongoing authorisation form instead on our website at www.playcentre.org.au/forms
I
Parent Name
*
First
Last
AUTHORISE
Name of Person Collecting Child
*
First
Last
Date of Birth of Person Collecting Child
DD
/
MM
/
YYYY
Of:
*
Street Address
City
State / Province / Region
Postal / Zip Code
Phone
*
###
-
###
-
####
TO COLLECT MY CHILD
Child's Name
*
First
Last
On the following date:
*
DD
/
MM
/
YYYY
This will be a ONE-OFF occasion and this person is not to be included on my child’s enrolment form as an authorised nominee to collect my child on an ongoing basis.
Parent Signature
*
Clear
Date Time
*
DD
/
MM
/
YYYY
Parent Email
*
