OLD VERSION
Washington State School
for the Blind Transportation
Department
Phone 360-696-6321 ext.
122 FAX 360-737-2120
RELEASE FORM
ALTERNATE
TRANSPORTATION PLAN
I hereby release the State
of Washington, Washington State School for the Blind, and any of its employees
from the obligation of transportation for my child on the following dates.
Date regular
transportation is to be cancelled: __________________________
Alternate Travel Plan: Public transportation _____ Private Car _____
Time and date child will
leave campus: _____________________________.
If by public
transportation - Mode of travel: Train
_____ Bus _____ Plane _____
Ticket attached? _________________________________________________
If by private transportation - Person
picking up child ________________________
Address:
________________________________________________________
Telephone Number
_______________________________________________
If problems with transportation, parent can
be reached at ___________________
_______________________________________________________________
Time
and date child will return to campus: ______________________________
I understand that WSSB will not be responsible for supervision
of my child after he/she leaves the campus.
I understand that on all other weekends, my child will
be transported via scheduled means.
______________________________ __________________________
Signature
of Parent Student
name
Date ___________________
2nd and 3rd forms (all consolidated into one
form)
Liability Release and Permission Form
(To be filled out by parent/guardian)
Date: __________________________
I, __________________________________,
give my permission for my child, ___________________________________,
to stay at the home of ___________________________________ on the
following dates: ____________________________.
I hereby release the Washington State
School for the Blind of responsibility for the supervision of my child from the
above designated time until the time of return to WSSB.
Signature: __________________________________________
Address: ___________________________________________
___________________________________________
Phone: ____________________________________________
Alternate
Phone: _____________________________________
Liability Release and Permission Form
(To be filled out by host family)
Date: __________________________
I, __________________________________,
accept full responsibility for ____________________________________ for
the following dates: ____________________________________.
I release the Washington State School for
the Blind from liability during this time.
Signature: ____________________________________________
Address: _____________________________________________
______________________________________________
Phone: ______________________________________________
Alternate
Phone: _______________________________________
NEW VERSION
STUDENT ALTERNATE TRAVEL & LIABILITY RELEASE FORM
I hereby release the State
of Washington, Washington State School for the Blind, and any of its employees
from liability/responsibility for the supervision of:
(Student’s Name)
Student will be supervised
by: ____
Address
where student will be staying: ___________________________________ _____ __________ ____
Telephone
Number ______________________ ___________________ ____
Time and date student will
leave campus: _ __________ ___
______________.
Time
and date child will return to campus: ___________ ______ __________
Please state
transportation arrangements: _
Transportation
provided by: _ __________________
If
problems with transportation, parent can be reached at _ __________ ____
_____________________ ________________________________________
I understand that WSSB
will not be responsible for supervision of the student listed above after
he/she leaves the campus.
___________
_ _____ ___ ________ _____
Student’s Parent/Guardian Signature Date
________ ________
_______ __
__ __________
Signature of Person Accepting Student Date
WSSB Transportation Department (360) 696-6321 ext. 122