Emergency Child Removal Authorization Form
Child Information
Child's Full Name
Date of Birth
Current Address
Parent/Guardian Information
Parent/Guardian Name
Relationship to Child
Contact Phone Number
Authorized Individual / Agency
Name of Authorized Person/Agency
Contact Phone/ID (if applicable)
Details of Emergency Removal
Date and Time of Removal
Reason for Emergency Removal
Location Where Removal Will Take Place
Authorization & Consent
I hereby authorize the above individual/agency to remove my child from the location listed during the emergency situation described. I understand this is for emergency purposes only.
Parent/Guardian Signature
Date