2024 TRANSPORTATION and EMERGENCY AGREEMENT
I understand and agree to allow (name of participant) _____________________________________________________ to be transported by Autism ASK Employees.
RELEASE OF LIABILITY:
I give my permission for the above named to be transported to and from and to participate in outing(s) and local recreational activities supervised by Autism ASK staff.
In the event medical attention is needed, I give Autism ASK permission to pursue treatment with the nearest medical facility.
Insurance Name: ______________________________________________________________
Insured name:_________________________________________________________________
Policy number: _______________________________________________________________
Current medication or allergies: __________________________________________________
I release the provider, Autism ASK, and the contracting agency from all liability resulting from the above named participation in transporting and the activity.
________________________________________________ _____________________
Individual 18+/Parent//Legal Guardian Date
________________________________________________
Relationship
Cell phone of participant ____________________________
Emergency contact name, relationship and cell number ________________________________________________
I understand and agree to allow (name of participant) _____________________________________________________ to be transported by Autism ASK Employees.
RELEASE OF LIABILITY:
I give my permission for the above named to be transported to and from and to participate in outing(s) and local recreational activities supervised by Autism ASK staff.
In the event medical attention is needed, I give Autism ASK permission to pursue treatment with the nearest medical facility.
Insurance Name: ______________________________________________________________
Insured name:_________________________________________________________________
Policy number: _______________________________________________________________
Current medication or allergies: __________________________________________________
I release the provider, Autism ASK, and the contracting agency from all liability resulting from the above named participation in transporting and the activity.
________________________________________________ _____________________
Individual 18+/Parent//Legal Guardian Date
________________________________________________
Relationship
Cell phone of participant ____________________________
Emergency contact name, relationship and cell number ________________________________________________
