Authorization to Transport a Minor

Authorization to Transport a Minor
Client Information
Legal Name *

First Name Last Name
Preferred Name

First Name Last Name
Date of Birth *

Month Day Year
NWMHC follows the MN Child Passenger Safety Statutes when transporting minor children. NWMHC does not transport children that are not clients of the agency or children under the age of 5:

In Minnesota, all children must be in a child restraint until they are 4 feet 9
inches tall, or at least age 8, whichever comes first.
- Booster seats are used after outgrowing a forward-facing harnessed restraint
- Seat belts are used when children can sit with their back against the vehicle seat and have their knees bent comfortably over the edge with their feet touching the floor.
Based on the guidelines above, the child requires: *

A Booster Seat A Seat Belt
I understand the child is required to follow all applicable laws regarding riding in a motor vehicle and follow the directions of the driver. If not followed, transportation will not be provided in the future. *

YES
I recognize motor vehicle transportation may pose a risk to personal injury or permanent loss. I hereby attest and verify I have been advised of the potential risks, and I have full knowledge of the risks involved in transporting, and I assume any expenses incurred in the event of an accident, illness, or other incapacity. *

YES
I have read this authorization form and I fully understand its terms and conditions. I authorize Northwestern Mental Health Center to transport this minor child, driven by an individual authorized by Northwestern Mental Health Center for the purpose of providing treatment in accordance to the written treatment plan. *

YES
Please indicate your relationship to the client *

Parent Legal Guardian Conservator Health Care Agent / Health Care Power of Attorney
Parent Name *

First Name Last Name
Legal Guardian Name *

First Name Last Name
Name of Conservator Health Care Agent / Health Care Power of Attorney *

First Name Last Name
My signature indicates that I am legally authorized to sign on behalf of the client.
Authorized Signature *

Clear
Date *

Month Day Year
Should be Empty: