First Name *

Last Name *

Email *

Phone *

Please provide the first and last name of each child (including nickname), their age and height you are giving permission to transport as passengers. Do not include PII or sensitive information (birthday, addresses, etc.)

Please provide any information that would be helpful to know when transporting your child (e.g., allergies, disabilities/ service animal need).

You certify that you are the parent or legal guardian of the child/children named above.

Yes

Please provide the first and last name, and phone number for emergency contact.

On each day of service you agree that a responsible adult or sibling will be present at the drop off location at termination of the trip.

Yes

Date *

Your Signature *

Clear

By checking this box you authorize Ellis-Lopez Travel Partners Benefit LLC to transport your child.