Release Authorization

We understand that situations may arise that prevent you from being present to receive the participant at the time of drop off at the residence. The Release Authorization form is to authorize another person(s) (i.e. family member, neighbor, care giver, etc.) to receive the participant. Please fill in the information requested, sign the release, and click the “Submit” button on the form. Customer Service will receive the form and ensure that it is processed.

Your Name
First Last
Regional Center
Participant's Name
First Last
Check Below:*
- Release of this participant to the care of the person(s) indicated below, in my absence.
Authorized Person(s)
How Many Authorized Persons?
Authorized Person #1 – Name
First Last
Authorized Person #1 – Address
Street Address City State / Province / Region ZIP / Postal Code
Authorized Person #1 – Phone
Authorized Person #2 – Name
First Last
Authorized Person #2 – Address
Street Address City State / Province / Region ZIP / Postal Code
Authorized Person #2 – Phone
Authorized Person #3 – Name
First Last
Authorized Person #3- Address
Street Address City State / Province / Region ZIP / Postal Code
Authorized Person #3 – Phone
Digital Signature
I understand that by digitally signing this authorization R&D Transportation Services, Inc., the transportation provider, the driver, and the Regional Center are released of any liability once the participant is delivered as instructed.
Your Digital Signature*
Print your full legal name.
Relationship to Participant
Date
Phone
Participant UCI#
Program
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Please Note

Upon R&D’s receipt of this form, a phone call will be made to the home to confirm your authorization before the driver is notified to release the participant unattended.
The participant must have access to enter the residence and be able to enter the residence on their own.
No statements, other than the required information that is asked, can be written on the Release Authorization Form. Otherwise, the form cannot be processed and this Release Authorization form will not be valid.

Authorized Person(s)

Digital Signature

Please Note