*This form is not to

be used for field trips

or other off premise
BLANKET PERMISSION FOR ROUTINE TRANSPORT OF CHILDREN activities.

Complete this form for routine/everyday transportation, before and afterschool pick-up and drop off

Center Name: _____ Luxury Learning______________ Date:________________

I ________________________________________give permission for ___________________________

(Parent/Guardian) (Child’s name)

to be transported to ____________________________________________________________________.
(Where)

Departure Time________________ Return Time___________________

Method of Travel (please circle one of the following: van, car, bus)

Transportation Provider(s) __________________ _____________________

__________________ _____________________

Other pertinent/important information______________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________

*Blanket Permission is valid for 12 months

Permission to transport is valid for ____________________ to ____________________.

Signature of Parent/Guardian_________________________________________ Date _____________.

Signature of Director/Designated Individual_____________________________ Date _____________.