DFCS Transportation Referral and Consent Form
Please complete this form to authorize Brightside Child & Family Advocacy to transport children in the care of DFCS.
Child / Youth Information
Provide the child's information below.
Rows
Child's Name
DOB
Placement Name & Phone #
Reason for Transportation
Child's Info
Child's Info
Child's Info
Child's Info
Child's Info
Authorization for Transportation
Select the transportation purposes for which you give consent.
I give permission for Brightside Child & Family Advocacy, Inc. to transport the above-named child(ren). By giving permission, I certify that I am DFCS representative authorized to give permission to transport the above mentioned child(ren). I understand that: transportation will be provided using organization-owned or approved vehicles. All passengers are required to wear seatbelts at all times. Brightside staff follow strict safety, supervision, and documentation protocols. This consent may be revoked by me at any time in writing. Transportation may include travel to and from:
*
Supervised visitation
Court appearances
Other (please specify)
Authorized Transporters
Indicate who is authorized to provide transportation.
Transportation will be provided by:
*
Any approved Brightside transporter
Only the following individual(s) (optional)
Dates of Authorization
Specify the period for which this consent is valid.
This consent is valid for:
*
A single date
Date range
Until revoked in writing
Single Date (if selected above)
-
Month
-
Day
Year
Date
Date Range (if selected above) - From
-
Month
-
Day
Year
Date
Date Range (if selected above) - To
-
Month
-
Day
Year
Date
Transportation Details (if known)
Provide pickup and drop-off locations if available.
Pickup Location(s): Name, address, phone number
Drop-off Location(s): Name, address, phone number
Time Child Needs to Arrive at Drop-off Location
Hour Minutes
AM
PM
AM/PM Option
Is this one way or round trip?
Please Select
One way
Round Trip
If round trip provide return location if it's different than pickup location.
Return location for round trip if different from pickup location:
Emergency Authorization
Authorize emergency action if needed during transportation.
In the event of a medical or safety emergency during transportation, do you authorize Brightside staff to take reasonable action to protect the child’s safety, including seeking emergency medical care if necessary?
*
Yes, I authorize emergency action
No (please explain)
DFCS Representative
.
DFCS Representative Name
First Name
Last Name
Date (DFCS Representative)
-
Month
-
Day
Year
Date
If this is for supervised visitation, does the visiting party also need transportation?
Please Select
Yes
No
Ask Visiting Party
Submit Consent Form
Should be Empty: