Release to Self Authorization

Your Name
First Last
Regional Center
Participant's Name
First Last
Check Below:*
- Delivery of this participant without the presence of adult supervision.
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
Name
This field is for validation purposes and should be left unchanged.

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.

Digital Signature