Legal Gardian Name
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)
Hospital of choice
By typing your name and date below your are agreeing to electronically signing the above document.
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
A copy of your responses will be emailed to the address you provided.
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