1.What is the name of the parent, caretaker, or qualified individual requesting the youth's participation in the transport services?

2.What is the youth's name?

3.What is the youth's phone number?

4.What is the youth's address?

5.I am permitting Don't Look Back Transports to provide transports to:

In Patient Treatment

Out Patient Treatment

12 Step Meeting

Mental Health Appointment

Other

6.If you selected "Other" please state where.

7.I understand that this documentation is required before youth under 18 years of age are permitted for transport. By agreeing to this survey I/ WE do acknowledge and approve transport in the vehicles that are provided/ or rented by the Don't Look Back Transport Services Peer Navigators.

Yes

No

8.I understand that reasonable precautions will be taken to provide for the student's safety during transport. I/We, the parent's or guardian's of the named student, request that he she be transported as stated, and relieve and absolve Rise Up Central Kansas a taskforce of Central Kansas Partnership, and Peer Navigator, of any responsibility or liability other than stated above. My name in the provided textbox is proof of agreement to these terms.

9.Please provide emergency contact name and phone numer in the provided comment box.

10.By completing this survey, I acknowledge and agree to the terms outlined.

Yes

No