Minor Consent for Transportation – Peak Family Transport LLC

Age Policy: Children under the age of 13 require specific approval by Peak Family Transport LLC to travel without a parent or guardian.

Children 13 and over may travel without a parent or guardian with the written consent of the parent, as provided below.

Authorization Statement

I, (name), hereby affirm and attest that I am the parent/legal guardian of the above named minor. This minor is eligible to receive Health First Colorado funded services, including transportation under the Non-Emergency Medical Transportation (NEMT) program. I hereby authorize Peak Family Transport LLC to transport this minor without an adult escort. In compliance with the state's requirements, an adult will be present to accept the minor at the destination and return location.

Liability Release: By authorizing Peak Family Transport to arrange transportation, I hereby release and indemnify Peak Family Transport LLC, its employees, officers, agents, parent company and affiliates and providers and their employees, officers, agents, parent companies, and affiliates of any and all liability, causes of action, or claims of any nature whatsoever arising from or in connection to the transportation provided.

* Required fields

Minor's Information

Minor's First Name * Please enter the minor's first name.

Minor's Last Name * Please enter the minor's last name.

Minor's Date of Birth * Please enter the minor's date of birth.

Minor's Age

Guardian Information

Guardian's Printed Name * Please enter the guardian's full name.

Relationship to Minor * Please enter relationship.

Contact Phone # * Please enter a valid phone number.

Guardian's Email * Please enter a valid email address.

Home Address * Please enter your home address.

Guardian's Signature *

✍️ Typing your full name constitutes your legal electronic signature.

Please provide your signature.

Date Signed * Please select a date.

Authorized Individuals to Receive Minor

Important: Please list up to three (3) individuals who are authorized to receive this minor upon arrival, in addition to employees of the receiving organization. Each listed individual must present a valid Colorado-issued photo ID at the time of drop-off. At least one authorized person is required.

Authorized Person #1

Required

First Name *Required

Last Name *Required

Date of Birth *Required

Gender *Required

Phone Number *Required

Relationship to Minor *Required

Home Address *Required

Email Address (optional)

Colorado-Issued Photo ID *

🏔 Colorado ID

📷

Upload Colorado-Issued Photo ID

Driver's License, State ID, or Passport · JPG, PNG, PDF

Please upload a Colorado ID for this person.

Authorized Person #2

Optional

First Name

Last Name

Date of Birth

Gender

Phone Number

Relationship to Minor

Home Address

Email Address (optional)

Colorado-Issued Photo ID (if listing this person)

🏔 Colorado ID

📷

Upload Colorado-Issued Photo ID

Driver's License, State ID, or Passport · JPG, PNG, PDF

Authorized Person #3

Optional

First Name

Last Name

Date of Birth

Gender

Phone Number

Relationship to Minor

Home Address

Email Address (optional)

Colorado-Issued Photo ID (if listing this person)

🏔 Colorado ID

📷

Upload Colorado-Issued Photo ID

Driver's License, State ID, or Passport · JPG, PNG, PDF

Child Health & Safety Information

Please complete this section carefully. This information is shared with the driver and dispatcher to ensure the child's safety during transport. All information is kept strictly confidential.

Special Needs / Disabilities / Medical Conditions (if applicable) Include any accommodations the driver should be aware of.

Does the child have any allergies that could result in anaphylaxis? * Please indicate whether the child has anaphylactic allergies.

⚠️ Anaphylaxis Alert — Please Complete All Fields

Known Anaphylactic Allergens * Please list the allergens.

Does the child carry an Epi-Pen / Auto-Injector? * Please indicate Epi-Pen status.

Action if Reaction Occurs * Please select an action protocol.

Additional Allergy / Emergency Notes (optional)