Revoke Authorization

  • Digital Signature

    I understand that by digitally signing this revoke request that the signed release authorization on file be revoked within five (5) business days of receipt of this signed request. I understand that by digitally signing this revoke request, I agree an adult will wait for the bus, with the participant in the morning, and will wait for the bus and the participant at the scheduled return time. If an adult is not present upon return of the bus, R&D Transportation Services, Inc., the transportation provider, the driver, and the Regional Center are authorized to make the necessary arrangements to deliver this participant to an alternate location until such time I can retrieve her/him
  • Print your full legal name.