Request for Out-of-County Travel to Visit a CASA Child
Approval must be obtained before a CASA/GAL can be reimbursed for mileage for out-of-county travel to visit a CASA child in an out-of-home placement. Please submit this form at least 10 days prior to your intended travel date by clicking on the "Submit" button at the bottom of the form, after the "For Office Use Only" section. You will be notified of approval or denial by the CASA/GAL Office. If approved, be sure to confirm plans with the caregiver again immediately before traveling.

Please remember: You need to submit a Mileage Reimbursement Form after you have completed your approved trip.
Current Date: *
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Case #: JC
CASA/GAL Name: *
CASA/GAL's Telephone #: *
Child's Name: *
Child's Age: *
Date of Intended Travel (Visit): *
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Child(ren)'s Address: *
County:
City: *
State: *
Child's Placement: *
Check One:
If you checked "Hospital" or "Institution" in the previous question, please list the name of the hospital or institution here:
If you checked "Other", please explain below:
The box will expand at the bottom, if needed.
Number of miles (ROUND TRIP): *
Date of last visit with child: *
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Reason in-person contact is needed: *
The box will expand at the bottom, if needed.
For CASA Office Use Only:
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Clear selection
By:
Date:
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CASA Notified:
Clear selection
By: (Name)
Date Notified:
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Notification By:
Clear selection
Submit
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