Written notice from Parent/Guardian must be given to MOM prior to someone other than those listed on this form can pick up. MOM Staff reserve the right to not release any child to an unauthorized pick up person. MOM Staff may ask for Identification upon releasing a student to someone other than his/her parent.
Name of Educator(s) responsible for child: Staff of M.O.M.
Name of off-site location and address:
Pappas Recreational Fields and Playground
203 Pakachoag Street
Auburn, MA 01501
Date of off-site activity: daily
Method of Transportation: walk