Great Lakes Academy
46312 Woodward Ave. Pontiac, MI 48342 Phone: 248‑334‑6434 Fax: 248‑334‑6457
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Student Pick Up / Release Form

STUDENT RELEASE

Adults who are not listed as an emergency contact or authorized pickup will not be allowed to pick-up a student.

PICKUP LIST

Only adults listed by the parent or legal guardian on the “pickup list” will be permitted to take a child from school. If a person is being added to the pickup list, the information must be provided in writing, with parent/guardian signature, to the main office. The school will not accept additions to the pickup list by phone.

STUDENT DISMISSAL ARRANGEMENTS

Any changes made to your child’s dismissal procedure (walker or pick-up) must be given to the school in writing. GLA will not accept phone calls to change student dismissal arrangements. EX: If student is designated as a “pick-up”, we cannot accept a phone request that the student should walk home today. This change must be submitted in writing with a parent signature.

Changes to dismissal procedures may be sent to school with the child or sent via fax to 248-334-6457 (if using fax, please be sure to include a copy of your identification.)

It is the sole responsibility of the parent/legal guardian to ensure the school office has the correct emergency contact and pickup information.

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Student Information
Student Last Name:*
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Student First Name:*
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Student Middle Name:
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Grade:*
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Parent/Guardian Information
Parent/Guardian Name:*
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Email:*
Must be a valid email address

Please check one*

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List of Adults Authorized to Pick Up Student
Name
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Phone #
valid phone number please

Relationship to Child
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Name
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Phone #
valid phone number please

Relationship to Child
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Name
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Phone #
valid phone number please

Relationship to Child
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Name
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Phone #
valid phone number please

Relationship to Child
Invalid Input


Name
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Phone #
valid phone number please

Relationship to Child
Invalid Input

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