Parental Permission Form For Off-Premises Trips - Kansas Department Of Health And Environment

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Kansas Department of Health and Environment
CCL. 034
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: 785-296-1270
Fax: 785-559-4244
Website:
PARENTAL PERMISSION FORM FOR OFF-PREMISES TRIPS
Name of the Facility (exactly as stated on the license)
License #
Street Address of the Facility
City
Zip Code
County
_______________________________________may go to the following locations off the premises with adult supervision:
First and Last Name of Child or Youth
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed

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