Hand in Hand
3860 Middle Road
Bettendorf, Iowa 52722
email us: info@handinhandqc.org

Phone: (563) 332-8010   Fax: (563) 332-7396
Pick-Up Authorization Form
To ensure the safety of your child, we will ask the individuals listed below to show a photo ID.
Parent or Guardian name:*
Parent or Guradian email address:*
Child's Name:*   Age:*
I authorize the following individuals to pick up my child from the Hand-in-Hand programs:

Name:*     Phone:*

Name:     Phone:

Name:     Phone:

Name:     Phone:

Name:     Phone:
      * - Mandatory Fields.

Hand-in-Hand is a non-profit organization that assists families with special needs. We exist to expand the capabilities, confidence and quality of life for children and young adults of all abilities by providing programs designed to encourage fun, learning and social interaction in a positive environment.