MN DHS Travel and Activity Authorization
List the applicable child(ren)
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List the applicable child(ren) ages
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Select all that apply
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I give permission for my/our child(ren) to leave the family child care home for travel in a car or on public transportation for any reason. I understand that the provider will always use proper safety restraints and will never leave any child unattended in a vehicle
I give permission to walk toand/or participate in activities geared for my child, but away from the child care home under thesupervision of a provider or adult helper. My provider will inform me in advance of field trips beyondthe immediate neighborhood. (park, library, local pool)
I give permission for my/our child(ren) to participate in the indicated activity outside the residence. I understand my child will not be under the supervision of the child care provider, substitute, or helper
List the applicable child(ren)
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List the applicable child(ren)
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Activity
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Signatures
I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Parent/Guardian Name
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First Name
Last Name
Parent/Guardian Email
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example@example.com
Parent/Guardian Signature
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Date of Signature
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Month
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Day
Year
Date
I have clicked "Preview PDF" and reviewed my form for accuracy
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Yes
No
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