GEORGIA DEPARTMENT OF HUMAN RESOURCES - GA+SCORE



Name of Youth: FORMTEXT ?????Age of Youth: FORMTEXT ?????Youth is requesting to: (check all that apply) FORMCHECKBOX Attend Driver’s Education Courses FORMCHECKBOX To Obtain a Driver’s License FORMCHECKBOX To Drive a Motorized VehicleI/We, FORMTEXT ????? parents of the above named minor youth in the placement authority of the FORMTEXT ????? County Department of Family and Children’s Services (DFCS) understand that I/We retain the right to determine whether my/our child can participate in a Driver’s Education course, obtain a Driver’s License, and/or drive a motorized vehicle. Further, I/We understand that if permission is given, that I/We will be assuming responsibility for any acts or injuries caused by my/our child’s driving, and that I/We will be responsible for any liability. Having read and discussed this statement with a representative from DFCS, I/We grant permission for my/our child to participate in one or all of the following: (check all that apply) FORMCHECKBOX Attend Driver’s Education Courses FORMCHECKBOX To Obtain a Driver’s License FORMCHECKBOX To Drive a Motorized VehicleBy signing this form, you are indicating that permission is granted for your child to attend Driver’s education, obtain a Driver’s license, or drive a motorized vehicle. You also acknowledge that you are accepting further liability for any damages or injuries that may occur as a result of your child’s driving. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DateSignatureRelationship FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DateSignatureRelationship FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DateCounty Department RepresentativeTitle FORMCHECKBOX No, I/We do not give permission for my/our child to participate in Driver’s education, obtain a Driver’s license or drive a motorized vehicle. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DateSignatureRelationship FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DateSignatureRelationship FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DateCounty Department RepresentativeRelationship FORMCHECKBOX Birth or Adoptive Parents have not been located. Based on the youth’s request, the FORMTEXT ????? County Department of Family and Children Services grants permission for the youth to: (check all that apply) FORMCHECKBOX Attend Driver’s Education Courses FORMCHECKBOX To Obtain a Driver’s License FORMCHECKBOX To Drive a Motorized Vehicle FORMCHECKBOX Birth or Adoptive parents have not been located. Based on the youth’s request, the FORMTEXT ????? County Department of Family and Children’s Services does NOT grant permission for the youth to attend Driver’s education courses, obtain a Driver’s license or drive a motorized vehicle.DateSSCMDateSSSDate County DirectorFile the original in the Case Record, Upload to Georgia SHINES external documentation and provide copies to the parent. ................
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