Authorization and Waiver to Transport Child
Authorization Is Valid: June 1, 2012-June 30, 2013
Child’s First Name: _____________________________ Child’s Last Name: _____________________________
Child’s Date of Birth: _________________
My child requires a booster seat:
Yes No (All children under 8 years of age are required to be in a booster seat)
I authorize Footsteps Child Care, Inc. to transport my minor child in a company Bus or Van, driven by an individual
authorized by Footsteps Child Care, Inc. I understand my child is expected to follow all applicable laws regarding
riding in a motor vehicle and is expected to follow the directions provided by the driver and/or staff or volunteer. I
understand participation in the identified event is not a requirement for participation in the program.
I have read, understand, and discussed with my child:
(1) My child will travel in a motor vehicle driven by an adult and my child is to wear their safety belt during
travel;
(2) My child is expected to listen to supervising staff/driver, respect staff and other children, the vehicles they
ride in, and the people they travel with during the trip;
(3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders,
other drivers, or objects; and,
(4) My child is to remain in their seat and not be disruptive to the driver of the vehicle.
Initial Each Statement
_______ I recognize participation in this activity, as with any activity involving motor vehicle transportation, my
child may risk personal injury or permanent loss. I hereby attest and verify I have been advised of the potential
risks, and I have full knowledge of the risks involved in this activity, and I assume any expenses incurred in the
event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.
_______ As a condition for the transportation received, I, for myself, my child, my executors and assigns, further
agree to release and forever discharge Footsteps Child Care, Inc., and their agents, officers, employees and
volunteers from any claim that I might have myself or that I could bring on my child’s behalf with regard to any
damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this
transportation.
_______ I have read this entire waiver and authorization form, I fully understand its terms and conditions, and I
agree to be legally bound by its terms.
Parent/Guardian Name: _________________________________________________________________________
________________________________________________________________ _________________________
Parent/Guardian Signature Date
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signature
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