Youth Transportation Form

Johnson County Juvenile Community Corrections Transportation Approval for Program Participant

Youth Name

Youth Date of Birth

Date

Program Name

Person Completing this Form

Relationship to Youth

Please list the name of any individual approved to pick your student up from class. This person must come inside the building with their state issued identification and sign the student out before the student can be released.

Name of Approved Person 1

Relationship to Approved Person 1

Phone Number for Approved Person 1

Name of Approved Person 2

Relationship to Approved Person 2

Phone Number for Approved Person 2

Approved Person 3

Relationship to Approved Person 3

Phone Number to Approved Person 3

Is your student driving to and from class?

YesNo

If yes record drivers license number here

Please verify that you are human*