Consent for Kids & Young Adults for Transportation Services

Parental Consent for Transportation Services

PARENTAL CONSENT

To Whom It May Concern: (Families, Government Officials, Law Enforcement, Parents Guardians, and Extended Family of the child being serviced by Eastern Shore Transit:

The undersigned will hereby these terms as it pertains to our Kids and Youth Transportation services or other services where adolescents 16 and older can travel alone which we will explain in further detail. The parent(s) or guardian(s)s give permission for their child to travel point to point with Eastern Shore Transit's personal transportation services or participate in all sponsored activities such as trips or visiting Maryland correctional facilities where the law requires that anyone 16 and older can visit.

Please advise we do provide the option for parents and guardians who continuously use our services , to select below if they would like for the parental consent to be a withstanding consent for all services up to one year. The consent will only apply to one child and parents and guardians are responsible to complete the parental consent for each child. We encourage to please review our Terms Service Agreement

Contact Us

Service Type

Date of Service:

Parent's or Guardian Name:

Parent or Guardian Name: 2

Phone Number:

Secondary Contact Number:

Child's Name:

Child's Birthdate:

School Name:

Emergency Contact Name:

Emergency Contact Number:

Hospital Insurance:

In the event of a emergency, which patient care or hospital would you like for your child to go?:

Who do we contact in the event of a emergency:

Please provide any medical conditions as it may pertain to your child and the transportation service received:

Will your child travel alone for this service?:

Authorize Party to drop your child off with :

Authorize Party Phone Number:

Photo of Authorize party to ensure the right person:

Would you like for this consent to apply to all future transportation services up to 1 year?:

Completed By:

New Field:

Today's Date:

Time

Opt-In

I have read, agree to share my information & understand the Terms Service Ageement as it pertains to Eastern Shore Transit Kid & Youth Transportation Services and understand that checking the box is a form of signature & that I am 18 or older.