Transportation Release
* Required
Email address
*
Your email
Date
*
MM
/
DD
/
YYYY
Client Name
*
Your answer
Legal Gardian Name
*
Your answer
I understand that by giving my permission to transport the above named client, I am releasing Eclipse Therapy LLC and its' employees from liability related to the transportation of this client.
In case of emergency please list:
Emergency contacts (name and phone)
*
Your answer
Hospital of choice
*
Your answer
By typing your name and date below your are agreeing to electronically signing the above document.
*
Your answer
By typing your name in the above box, you are acknowledging your electronic signature of this document. Please check the box acknowledging your electronic signature.
*
I have typed my name above as my electronic signature
Required
A copy of your responses will be emailed to the address you provided.
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