Community Service Transportation Consent Form

Participant Information

Participant Name Date of Birth Address Phone Number

Parent/Guardian Information (if under 18)

Parent/Guardian Name Parent/Guardian Phone Number

Consent & Acknowledgement

I hereby give permission for the participant listed above to be transported by authorized personnel for the purpose of community service activities organized by the program.

I agree to the terms stated above.

Medical Information (allergies, medications, etc.)

Emergency Contact

Emergency Contact Name Emergency Contact Phone Number

Signature:

Date:

Parent/Guardian Signature (if under 18):

Date: