Fillable 9.11.13 Parent Transportation Authorization California State University, Fresno

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9.11.13 Parent Transportation Authorization California State University, Fresno

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California State University, Fresno
Speech, Language and Hearing Clinic
5310 North Campus Drive, M/S PH80
Fresno CA 93740-8019
(559) 278-2422 – Fax (559) 278-5187
Parent/Guardian Transportation Authorization Form
__________________________________ _______________________________
Client Name Semester
The following individuals have permission to pick up my child from the CSU, Fresno
Speech, Language, and Hearing Clinic each. I understand that these individuals will be
required to show identification in order to pick up my child and that my child must be
picked up from clinic on time each day.
1. _________________________________________________________________
Print name Relationship Contact number
2. ________________________________________________________________
Print name Relationship Contact number
3. _________________________________________________________________
Print name Relationship Contact number
4. _________________________________________________________________
Print name Relationship Contact number
5. _________________________________________________________________
Print name Relationship Contact number
__________________________________ _____________________
Parent/Guardian (print Name) Date
__________________________________
Parent/Guardian Signature
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9.11.13 Parent Transportation Authorization California State University, Fresno

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Completed 22 May 2020

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