Minor/Special Needs Person Release Form

Whenever there is a minor (17 years or younger) person whom is unaccompanied by an adult in our vehicles; a Minor Release Form is required. One form per minor is required unless the minor has the same parent or guardian or chaperone.

 

'Minor Release Agreement' - A 'Minor Release Agreement' is required for all persons under 18 years of age. This form is to be filled in and signed by the Parent, Guardian or Chaperone of the minor students and returned to My Chauffeur upon request. Failure to have this form for your minor student (17 years old and under) will disallow the minor from attending.

 

Part 1: PARENT, GUARDIAN OR CHAPERONE PLEASE NOTE:

1. The passenger(s) will be getting out of the vehicle by themselves.

2. My Chauffeur Transportation Co. does not assume any other responsibility for the unaccompanied minor/special needs passenger(s) traveler after providing service between the pick-up and drop-out locations.

3. This release needs to be valid for either a single date or a range of dates.

Part 2: AUTHORIZATION - MINOR OR SPECIAL NEEDS INFORMATION:

My minor/special needs person(s) will be getting out of the vehicle by him/her self at __________________________________________(destination)

I ______________________________, parent/guardian or chaperone of:

  1. Name:________________________________  Date of Birth:__________

  2. Name:________________________________  Date of Birth:__________

  3. Name:________________________________  Date of Birth:__________

  4. Name:________________________________  Date of Birth:__________

  5. Name:________________________________  Date of Birth:__________

  6. Name:________________________________  Date of Birth:__________

  7. Name:________________________________  Date of Birth:__________

  8. Name:________________________________  Date of Birth:__________

  9. Name:________________________________  Date of Birth:__________

  10. Name:________________________________  Date of Birth:__________

  11. Name:________________________________  Date of Birth:__________

  12. Name:________________________________  Date of Birth:__________

  13. Name:________________________________  Date of Birth:__________

  14. Name:________________________________  Date of Birth:__________

  15. Name:________________________________  Date of Birth:__________

  16. Name:________________________________  Date of Birth:__________

do give My Chauffeur Transportation Co. authorization to provide transportation between:

 ___________________________________________(departure location)

and:

  1. _________________________________(destination or final drop-off location)

  2. _________________________________(destination or final drop-off location)

  3. _________________________________(destination or final drop-off location)

  4. _________________________________(destination or final drop-off location)

  5. _________________________________(destination or final drop-off location)

I understand that My Chauffeur Transportation Co. is not acting as a guardian for the passenger(s) while on board the vehicle nor once the passenger(s) leaves the vehicle, whether on route or at the final destination.

My Chauffeur Transportation Co. is responsible for the transportation of the passenger(s) only.

I _______________________, parent/guardian or chaperone of the minor/special needs person(s) above authorize that the instructions specified above are valid for ___________________(starting date) to _____________________ (ending date)

Part 3: PARENT/GUARDIAN/CHAPERONE OR CONTACT PARENT INFORMATION:

Your signature confirms that you agree with the above authorization

Name:_______________________________ Signature: _________________________

Address:_____________________________ Date Signed: _______________________

City:________________________________ Cell Phone: ________________________

Alternate Contact in case of transportation emergency only (we suggest this is the contact info. of the receiving parent/guardian/chaperone)

Name:_______________________________

Cell Phone:___________________________