Iroquois-Kankakee ROE Teen REACH
Parental Consent for Transportation
To whom it may concern:
I hereby give permission for my child,
[Line for name of child]
, to be transported to and from the
[Line for name of Location]
Teen REACH program. I also give permission to provide transportation and for any emergency medical care that will be performed by a licensed physician if necessary. I agree to be liable and to pay for all costs and expenses that might incur in connection with such medical or dental services that were rendered.
Upon returning home, my child should be brought to [Line for Location]
Please Check one - This is [ ] / is not [ ] our home.
Parent / Guardian Signature: [Line for Signature]
Parent / Guardian Signature: [Line for Date]
