Transportation Permission

Fill this out on any device. When you finish, you'll get the official state form (DCF-F-CFS0056) completed with your answers, ready to print and send to PNCC.

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Child Information

Child's name *Home address (street, city, state, zip)

Does the child have any special health care needs?

yesno

Parent / Guardian 1

Where you can be reached while your child is in care.

Name *

Home phoneWork phoneCell phone

Second name (optional)

Home phoneWork phoneCell phone

Address (street, city, state, zip)

Parent / Guardian 2

Optional

Name

Home phoneWork phoneCell phone

Address (street, city, state, zip)

Emergency Contact

Who to contact if the parent / guardian cannot be reached.

NameAddress (street, city, state, zip)Telephone

Authorized Destinations / Persons

List up to 4 trips. Leave unused rows blank.

Trip 1

Transported from (street, city)Transported to (street, city)Length of trip (one way)Person authorized to receive child

Trip 2

Transported from (street, city)Transported to (street, city)Length of trip (one way)Person authorized to receive child

Trip 3

Transported from (street, city)Transported to (street, city)Length of trip (one way)Person authorized to receive child

Trip 4

Transported from (street, city)Transported to (street, city)Length of trip (one way)Person authorized to receive child

Procedure

What should the driver do if no parent, guardian, or authorized adult is at the destination to receive your child?

Procedure to follow

Child's Health Care Provider

Physician name

TelephoneAddress (street, city, state, zip)

Authorization

I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately.

yesno

I hereby give permission for my school-aged child to enter a building unescorted.

yesno

Signature

Sign with your finger or mouse.

Printed name *Date signed *