Transportation Information Form (Page 2 of 2) in pdf

Must someone meet the vehicle? ____________. If yes, please list all person (s) authorized to do

so:

(photo ID may be required for authorized person)

__________________________________________________________________________________

CHILDREN WILL NOT BE AUTHORIZED. CHILDREN WILL NOT BE LEFT WITH CHILDREN.

If the vehicle is delayed more than twenty minutes, the transportation staff will telephone the

home or emergency number. For morning pickups, the drivers will wait no longer than 2

minutes (with no response.)

SCUSA Transportation assumes no responsibility for passengers prior to pickup or after

discharge from the vehicle. Children (under the age of 18) shall not be left alone at the

discharge site. In the afternoons, driver will wait no longer than 10 minutes beyond the times

listed above, and will then take the passenger back to the point of pickup. The family members

of other authorized persons listed above will then be responsible for picking up the passenger.

The passenger must carry personal identification at all times.

How is transportation to be reimbursed?

_______ Stanly Industrial Services (ADAP, CAP, VR, other __________)

_______ Vocational Rehabilitation

_______ Day Care Agency

_______ DSS (Medicaid / Workfirst, other _________)

_______ Passenger Fee

_______ Mental Health Services (Daymark, Monarch, etc.)

_______ Other – please list: _______________________________

Please give arrangements and phone numbers for passengers in the event the facility or the

transportation office closes early for inclement weather or other unexpected events.

__________________________________________________________________________________

Please give any other information/assistance that you feel may be needed while transportation

services are being provided.

__________________________________________________________________________________

ALL PASSENGERS RIDING SCUSA VEHICLES ARE REQUIRED TO WEAR SELT BELTS. “A CHILD

LESS THAN EIGHT (8) YEARS OF AGE AND LESS THAN EIGHTY (80) POUNDS IN WEIGHT SHALL BE

PROPERLY SECURED IN ANAPPROPRIATE CHILD PASSENGER RESTRAINT SYSTEM.” IT IS THE

RESPONSIBILITY OF THE PARENT/GUARDIAN OR SPONSORING AGENCY TO PROVIDE A CAR SEAT

ON OR BEFORE THE FIRST DAY OF SERVICE.

These arrangements are approved by the parties signing below. Passenger or representative or parent/guardian

must sign this form. A copy of the agreement will be given to the passenger, driver and Transportation Director.

_________________________________________

_________________________

Passenger/or parent/guardian signature

Date

_________________________________________

_________________________

Transportation Director

Date

Transportation Information Form Page 2