RIDE WELL Youth Consent Form

Consent Letter for Youth Travelling with RIDE WELL™

To whom it may concern,

I / We,

Street Address

City

Province

Postal Code

Telephone

am / are the parent(s), legal guardian(s) or other authorized person(s) or organization with custody rights, access rights or parental authority over the following child:

Information about travelling child

Child’s full name

Date of Birth

Place of Birth

Province/Territory where birth certificate was issued

Information about accompanying person (leave blank if child is travelling alone

Full Name of accompanying person

Relationship to child

Declaration of Consent

I / We give our consent for this minor to travel with RIDE WELL™ services to any address within the County of Wellington and the City of Guelph:

Yes

Acknowledgement and Indemnity

I /We acknowledge that allowing the minor to use RIDE WELL™ is at my own risk.

I/We confirm that The Corporation of the County of Wellington is not responsible for the actions or inactions of the RIDE WELL™ Driver and/or service provider and that you are solely responsible for any and all losses and damages, directly or indirectly, arising from the grant of consent herein and will undertake to indemnify the County of Wellington from all such losses and damages.

Signatures of Consent

Date

Name of consented

Date

Signature of consented

Sign above

City, Province/Territory

Please sign, date and hit submit. A confirmation email will follow to the email provided above.

*The completed form/confirmation must also be presented to the driver via hard copy or digitally before entering the vehicle.

Privacy Notice

Personal information (PI) is collected in this survey under the authority of the Municipal Act, s. 11. The purpose of this collection is to administer the Wellington County RIDE WELL rural transit pilot programme. The PI provided in this survey is protected in accordance with Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). Should you have any questions or concerns regarding the collection of personal information (PI), please contact the Manager of Privacy and Information, County of Wellington, Office of the CAO, T 519.837.2600 x2528.

Form Revision Date: September 2020