Hamilton County Department Of Human Services - Transportation Services Consent Form
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Hamilton County Job & Family Services
Transportation Services Consent Form
Print
Please fax to: 513-946-1830
Children’s Services Information (if applicable):
Caseworker’s Name:
Phone:
Case Number:
Supervisor’s Name:
Phone:
Does HCJFS have custody of child?
Yes
No
Parent/Legal Guardian Information:
Parent/ Legal Guardian’s Name(s):
Parent/ Legal Guardian’s Name:
Street Address:
Street Address:
City:
State:
Zip:
Home Phone:
City:
State:
Zip:
Home Phone:
Work/Cell:
Work/Cell:
Child’s Information:
Child’s Name:
Date of Birth:
Weight:
Medical Problems/Special Needs:
Child’s Caregiver (if not living with parent/guardian listed above):
Home Phone:
Work/Cell Phone:
Street Address:
City:
State:
Zip:
Emergency Information: Please provide an emergency contact person below & the name of child’s doctor & preferred hospital
Emergency Contact Person:
Relationship to child:
Phone:
Doctor’s Name:
Phone:
Doctor’s Address:
Preferred Hospital:
Drop-Off Locations/Names: Please list any person to whom the contracted vendor may release the child and the drop off locations.
Authorized Drop-Off Names
Relationship to Child
Address/Zip Code
Phone #:
My signature below indicates that:
► I reviewed the NET transportation rules (HCJFS 3547) and authorize the child(ren) named above to be taken to the person(s)
and address(es) indicated above when the transportation provider picks up the child(ren) from the Provider.
► I give my permission to the Hamilton County Job & Family Services to arrange transportation to and from the therapeutic program
for the child named above.
► I understand an adult must be home at the time of drop-off. If no adult is home, the transportation provider will attempt to
make contact with all persons named above for drop-off. If unsuccessful, the driver will contact Hamilton County Children’s
Services (child’s caseworker, supervisor, or 241-KIDS) to receive direction on the most appropriate drop-off point for the child. I
understand my child may be suspended from transportation services should no one be at home for drop off three times within a
school year.
► I understand If the child presents with severe behavioral issues, the child may be suspended from transportation after 3 incidents
within a school year. Children presenting serious risks or inflicting injury to self of others may be suspended at least temporarily
after the first incident. Service will not be restored until a licensed professional documents the child is safe to transport.
► I understand this consent may be revoked by me at any time.
Signature of Parent or Legal Guardian:
Date:
Witness:
Date:
Original: Retained in case record
Copy 1:
Vendor
Copy 2:
Parent/Guardian
Copy 3:
Children Services
Copy 4:
DT/PH Program Site
HCJFS 3305 (REV. 4-13)
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