Form CCL.034 "Parental Permission Form for off-Premises Trips" - Kansas

This version of the form is not currently in use and is provided for reference only.
Download this version of Form CCL.034 for the current year.

What Is Form CCL.034?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL.034 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL.034 "Parental Permission Form for off-Premises Trips" - Kansas

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Kansas Department of Health and Environment
CCL. 034
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: 785-296-1270
Fax: 785-559-4244
Website: www.kdheks.gov/kidsnet
PARENTAL PERMISSION FORM FOR OFF-PREMISES TRIPS
Name of the Facility (exactly as stated on the license)
License #
Street Address of the Facility
City
Zip Code
County
_______________________________________may go to the following locations off the premises with adult supervision:
First and Last Name of Child or Youth
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Kansas Department of Health and Environment
CCL. 034
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: 785-296-1270
Fax: 785-559-4244
Website: www.kdheks.gov/kidsnet
PARENTAL PERMISSION FORM FOR OFF-PREMISES TRIPS
Name of the Facility (exactly as stated on the license)
License #
Street Address of the Facility
City
Zip Code
County
_______________________________________may go to the following locations off the premises with adult supervision:
First and Last Name of Child or Youth
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FOR SCHOOL AGE CHILDREN OR YOUTH ONLY
I hereby authorize my school age child ___________________________________________________________________
First and Last Name of Child or Youth
Birth Date MM/DD/YYYY
To walk/bike to and from the following location(s) without adult supervision:
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
Place
Street Address
City
By Vehicle
Walk/Bike
Signature of Parent or Guardian
Date Signed
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