Transportation Authorization Form

1. Staff Name: ___________________________

GA Driver License Number: _________________ Exp. Date___________

Name of Insurance Company__________________________ Policy #

______________

2. Staff Name: ___________________________

GA Driver License Number: _________________ Exp. Date___________

Name of Insurance Company__________________________ Policy #

______________

3. Staff Name: ___________________________

GA Driver License Number: _________________ Exp. Date___________

Name of Insurance Company__________________________ Policy #

______________

The above referenced staff member(s) are authorized to use their personal vehicle to
transport _________________________________________ for the following reason(s):
(Consumer/Family Member)
during the course of treatment.

___ Medical Related ____ Legal and Court Related Activities

___ Educational Related ____ Other: _____________________________

I acknowledge that transportation is voluntary and during transportation the staff member
will not knowingly or intentionally place me and/or my child(ren) in danger. The staff
member has my permission to notify or seek emergency assistance if unforeseen
circumstances occur if I am not present that may require any such public emergency
official services. My signature below signifies that I agree and release the staff person(s)
and the agency from all liability and cost related to transport services.

BH3501—Transportation Consent Rev Oct2008

_________________________________ _________________________
Parent / Legal Guardian Signature Date

BH3501—Transportation Consent Rev Oct2008