California State University, Fresno
California State University, Fresno
Speech, Language and Hearing Clinic
5310 North Campus Drive, M/S PH80 Fresno CA 93740-8019
(559) 278-2422 ? Fax (559) 278-5187
Parent/Guardian Transportation Authorization Form
__________________________________ _______________________________
Client Name
Semester
The following individuals have permission to pick up my child from the CSU, Fresno Speech, Language, and Hearing Clinic each. I understand that these individuals will be required to show identification in order to pick up my child and that my child must be picked up from clinic on time each day.
1. _________________________________________________________________
Print name
Relationship
Contact number
2. ________________________________________________________________
Print name
Relationship
Contact number
3. _________________________________________________________________
Print name
Relationship
Contact number
4. _________________________________________________________________
Print name
Relationship
Contact number
5. _________________________________________________________________
Print name
Relationship
Contact number
__________________________________ Parent/Guardian (print Name)
__________________________________ Parent/Guardian Signature
_____________________ Date
................
................
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