Transportation Agreement

This is to certify that I give (Name of Facility)
Permission to transport my child (Name of Child)
from (Pickup Location) at (am/pm)

to (Delivery Location) at (am/pm).

My child will be transported from (Pickup Location) at (am/pm)

to (Delivery Location) at (am/pm)

on the following days:

(Name of Authorized Person) is authorized to receive my child. In the event the authorized
person is not present to receive my child, the following procedures are to be followed:

The (Location) is approximately miles from the center. In the event

that my child is not to be transported as outlined above, I agree to notify the (Facility)

Signature (Parent/Guardian) Date

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