Breck Road Transportation Consent Form

Breck Road Transportation Consent Form

TeamCJColas Transportation Service

Monday- Friday 7am - 4pm
I give my permission for The TeamCJCoolas Uterine Cancer Foundation Transportation Service to be transported to and from the treatment center. I understand that I will be transported to/from the adresses on this form. I consent for them to travel in the transportation provided and participate in the activites at the stated event. I do not hold TeamCJColas Uterine Cancer Foundation responsible for any injury or loss/damage of property. Our Drivers do not accept any tips or monetary gifts from patients. This is a free service.

To:

Vanderbilt

Centennial Medical Center

Saint Thomas Medical Center
Name:*

First NameLast Name
Phone:*
Email
example@example.com
Address (Pick Up and Drop Off Location)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent/Legal Guardian:*

First NameSurname
Pick Up Date

MonthDayYear
Date
Date:*

DayMonthYear
Appointment Date and Time
Allergies
Anything we need to know
Signature of Parent/Legal Guardian:*

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