(413) 544-3401

QUABOAG CONNECTORPermission Form for New Riders Ages 12 – 18

I, the undersigned parent/guardian of  _____________________________ do hereby for myself, my heirs, executors and administrators, waive and release any and all claims or damages not covered by applicable insurance that I may have against the Quaboag Connector, the Town of Ware or the Quaboag Valley Community Development Corporation, and their representatives, successors, assigns for any and all injuries, illness and loss or damage pf personal property by the above-named person while boarding, exiting or travelling in a Quaboag Connector vehicle to or from any location.

In the event of an emergency I give permission for my child ____________________________ to be transported to the closes medical facility and receive treatment, if necessary.  (Print child’s name.)

If your child has a life-threatening allergy that emergency services should be made aware of, please provide details here:

Does your child carry an Epi-Pen?                 YES     NO

__________________                                ____________________________    ________________________

(Child’s Date of Birth)                     (Parent/Guardian’s Name – Print)           (Parent/Guardian Signature)

Home Address (use primary if there is more than one)

________________________________                                      _______________________________

Primary Phone (messages will be left here)                                    Preferred/Emergency Phone Number

________________________________                                      _______________________________

Parent/Guardian Email Address                                                                                Today’s Date

Please sign below to indicate that you & your child have reviewed the Safety Guidelines for Riding the Quaboag Connector (available on-line at www.rideconnector.com)

________________________                ________________________                                _______________

Parent Name (please print)                 Parent Signature                                            Date

________________________     ________________________                           _______________

Student Name (please print)              Student Signature                                           Date


Additional InformationParents may provide a cell phone number for their child so the driver can contact the child if necessary.  The driver will call only if a delay of 15 minutes or more is likely or if the dirver needs to clarify the connection point with the child.   Child’s cell phone number:   _____________________________


Please email the completed form to mail@qvcdc.org or fax it to 413.967.3008 (no cover needed).  Children’s Ride Requests cannot be accepted until this form has been received by the Quaboag Connector Dispatcher.