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Release and Waiver for Child Transportation

Release and Waiver for Child Transportation

I hereby consent and give permission for

to receive transportation and/or participate in actives related to treatment provided by PsyCare, Inc.

In consideration, I hereby release PsyCare, Inc., its drivers, staff, employees, volunteers, and cooperating organizations from damages, personal injury, or claims that my arise, and do further waive such claims and assume the risk thereof.

In case of accident, injury, or illness, I authorize PsyCare, Inc., to arrange for medical treatment (for which I shall assume financial obligation) as follows:

Hospital Preferred

Name

Address

Address

Address

Address

City

City

State

State

Zip

Zip

Phone

Doctor Preferred

Name

Address

Address

Address

Address

City

City

State

State

Zip

Zip

I hereby consent and give permission for

Phone

Alternate Hospital Choice

Name

Address

Address

Address

Address

City

City

State

State

Zip

Zip

Phone

Alternate Doctor Choice

Text

Address

Address

Address

Address

City

City

State

State

Zip

Zip

Phone

With the exception of the following restrictions/recommendations/precautions, it is safe for [name of minor listed bellow] to fully participate in the programs for which he/she has registered:

Please list any restrictions/recommendations/precautions if applicable:

Signature

Date

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