Authorised Persons Form

Details - Parent/Guardian 1

Name - Parent/Guardian 1*

First Last

Address - Parent/Guardian 1*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email - Parent/Guardian 1*

Re-enter Email - Parent/Guardian 1*

Phone Number - Parent/Guardian 1*

Name of child/ren*

List all children to whom the listed persons are authorised to pick up and/or be emergency contacts for.

Authorised Persons

Use this section to list any person who has authority to pick up your child/ren or be an emergency contact. You can add further authorised persons at any time my email or in person.

Name (authorised person 1)*

First Last

Relationship to child/ren (authorised person 1)*

Phone number (authorised person 1)*

Authority (authorised person 1)*

Pick up child/ren
Emergency contact

Tick all that apply.

Do you wish to add another authorised person?

Yes
No

Name (authorised person 2)*

First Last

Relationship to child/ren (authorised person 2)*

Phone number (authorised person 2)*

Authority (authorised person 2)*

Pick up child/ren
Emergency contact

Tick all that apply.

Do you wish to add another authorised person?

Yes
No

Name (authorised person 3)*

First Last

Relationship to child/ren (authorised person 3)*

Phone number (authorised person 3)*

Authority (authorised person 3)*

Pick up child/ren
Emergency contact

Tick all that apply.

Consents and Agreements

I confirm that all details in this form are true and correct and any changes will be communicated to MakerDojo in writing.

Authorised Persons Form

MakerDojo authorised persons form

Details - Parent/Guardian 1

Authorised Persons

Consents and Agreements