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VERBAL REQUEST FOR RELEASE OF CHILD 55 PA CODE CHAPTERS 3270. 117 c and 3280. 117 c and 3290. 116 c THIS FORM MUST BE COMPLETED TO DOCUMENT THE VERBAL REQUEST BY A PARENT FOR THE RELEASE OF A CHILD TO A PERSON S NOT INDICATED ON THE AGREEMENT CHAPTERS 3270. 123 a 5 3270. 124 b 7 3280. 123 a 5 3280. 124 b 7 3290. 123 a 5 3290. 124 b 7. NAME OF CHILD DATE TIME NAME OF REQUESTING PARENT TELEPHONE NO. FROM WHICH PARENT IS CALLING NAME OF INDIVIDUAL TO WHOM THE CHILD IS TO BE RELEASED NAME OF STAFF PERSON TAKING THE CALL CALL THE ENROLLING PARENT BACK TO CONFIRM THE INFORMATION IF POSSIBLE CONFIRMING PARENT BE SURE TO ASK FOR IDENTIFICATION WHEN THE INDIVIDUAL ARRIVES TO PICK UP THE CHILD CY 863 - 1/00. 123 a 5 3270. 124 b 7 3280. 123 a 5 3280. 124 b 7 3290. 123 a 5 3290. 124 b 7. NAME OF CHILD DATE TIME NAME OF REQUESTING PARENT TELEPHONE NO. FROM WHICH PARENT IS CALLING NAME OF INDIVIDUAL TO WHOM THE CHILD IS TO BE RELEASED NAME OF STAFF PERSON TAKING THE CALL CALL THE ENROLLING PARENT BACK TO CONFIRM THE INFORMATION IF POSSIBLE CONFIRMING PARENT BE SURE TO ASK FOR IDENTIFICATION WHEN THE INDIVIDUAL ARRIVES TO PICK UP THE CHILD CY 863 - 1/00.

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