Consent and Release of Liability
1. I, ____________________residing at_______________________________(address) hereby
affirm that I am the legal guardian of (name of minor)________________________________.
2. ____________________(name of minor) is_______ years old. His/her birth date is ________.
3. I consent to ______________________(name of minor) riding with any transportation
provider under contract with LogistiCare, in connection with his/her transportation for non-
emergency medical services.
4. By giving this consent and release of liability, I hereby represent that
_________________(name of minor) is fully capable of being transported without an adult
escort; will not be disruptive; will follow all rules communicated by the driver, and does not
need an escort to provide emotional or any other type of support.
5. I understand that if any of the factors set forth in paragraph 4, above, cease to apply, then
LogistiCare will no longer transport the minor without an escort.
6. I agree to inform LogistiCare within 48 hours if for any reason I cease being the legal
guardian of __________________________and to inform LogistiCare of the name and
address of the new legal guardian.
In consideration of LogistiCare’s agreement to transportation of the minor without an
escort, I hereby release LogistiCare and its employees, officers, agents, and subcontractors
from any and all liability, causes of actions, or claims in connection with his/her
transportation by LogistiCare and its subcontractors.
SIGNATURE OF GUARDIAN
PRINTED NAME OF GUARDIAN
NAME OF MINOR FOR WHOM CONSENT APPLIES
Please Fax form back to : 855-839-8664
FOR INTERNAL USE:
DATE RECEIVED BY LOGISTICARE
LOGISTICARE STAFF MEMBER