Consent And Release Of Liability printable pdf download

Consent And Release Of Liability

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

DATE

________________________________

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

Consent And Release Of Liability