Permission to transport a child: the parent consent form for a minor's ride

What the form does, and what it does not

The form records one parent’s consent and instructions for one child’s rides, and nothing more. It carries no liability waiver, and it does not authorize medical care. Virginia’s state manual draws the same line. A June 2026 member manual from the state Medicaid agency, written for the broker that served fee-for-service riders before MTM Health, says its consent form authorizes the minor to receive transportation and, when it applies, to ride with an attendant, and “is not a release of liability.” MTM’s current Virginia form only gives permission to schedule rides. Our guide to children on NEMT rides covers the car seat laws, the companion ages in five other programs, and who pays for the adult’s trip. This page is the paper you hand the parent.

On broker trips the program often has its own form. MTM Health’s Virginia consent form says MTM must receive the signed copy before it can schedule rides for the child, so a broker form is the broker’s to collect. Your own form fills the gaps the broker’s leaves: who hands the child over at pickup, who receives the child, which seat comes along, and which health alerts the driver should know.

Two programs that ask for consent, and what their paper says

The age line moves from program to program, and so does the paper.

Virginia fee-for-service Medicaid, run by MTM Health. Its member handbook (approved July 2026) says minors aged 12 and under must be escorted by an adult at all times, at least 18 unless the escort is the parent. Minors 13 to 17 may travel alone, but the parent or guardian must first complete a Minor Consent Form. MTM’s form asks for the child’s name, birth date, and Medicaid number, and for the name and relationship of the parent, guardian, or legal custodian. It gives MTM permission to schedule rides to and from Medicaid-related health visits when the parent cannot ride along and no other adult can. It takes effect on signing and stays in effect until the parent, or someone else with authority, writes to cancel it.

Missouri. The MO HealthNet NEMT manual (file dated April 2026), section 3.1, requires a participant under 17 to be accompanied by a parent or guardian, and lets the parent or guardian designate another adult, “family member or friend,” to go in their place. The broker must also arrange a ride for one parent or guardian to go along with any child under 21, if asked. The one exception is an unaccompanied youth as defined in RSMo 431.056, a section that lets certain 16 and 17 year olds who are homeless or victims of domestic violence, support themselves, and live independently contract for services that include medical care.

The two papers do different jobs. Virginia’s lets a teenager ride alone, and Missouri’s rule asks the parent to name the adult. Part 3 of the form below handles the Missouri kind of designation, and Part 4 handles the handoff for a teenager riding alone.

The form

Fill in the brackets, print one copy per child, and have the parent sign before the first ride.

[Company name] permission to transport my child

Part 3: Adults I allow to ride with my child. No other adult may ride along unless I confirm by phone at [number].

Part 4: Pickup and drop-off.

If no one is there to receive my child, the driver stays with my child and calls [Company name]‘s dispatch at [phone], and dispatch calls me and the contacts in Part 7 until someone arrives.

Part 5: Car seat or booster.

• ☐ Rear-facing seat ☐ Forward-facing seat with harness ☐ Booster ☐ Seat belt only ☐ Special seat or vest: ____________
• Brand and model: ____________ Fits a child up to: ____ lb and ____ in.
• Who brings it: ☐ the adult riding along ☐ [Company name] supplies one
• [Our drivers do not install car seats. If the right seat is not there at pickup, we cannot carry my child, and we will call me.]

Part 6: What the driver should know for the ride. Allergies, seizures, asthma, a device or stroller that comes along, or a need for advance warning or help with communication: ______________. [Our drivers do not give medicine. The adult with my child carries it and gives it.]

Part 7: Emergency contacts. In an emergency, [Company name] calls 911 first, then me, then these contacts.

Part 8: How long this lasts. This permission ends on [date or event, such as the last day of the school year or the last visit in a therapy series], or sooner if I cancel it in writing to [name, address, email].

Who may sign for the child

A parent or legal guardian signs, and anyone else shows the paper that gives them authority. Ask for a copy of the court order or agency document and keep it with the form. Three cases need a closer look:

• A court order limits who may pick up or ride with the child. Ask for the order and copy its limits into Parts 3 and 4.
• A child in foster care. The placing agency decides who may consent to transportation. Put that person’s name, phone, and the agency paper in Part 2, and read our guide to foster care transportation contracts for agency rides.
• A teen who lives on their own. Virginia’s handbook lets a member arrange rides alone if they are 18 or older or emancipated, so an emancipated minor needs the court paper on file, not a parent’s signature. Missouri’s unaccompanied youth exception covers a narrow group, and a parent form does not fit those riders. Follow the broker’s instructions for them.

A parent is generally the personal representative of an unemancipated minor under HIPAA, except for care the minor consented to alone (45 CFR 164.502(g)). That is why a parent can sign for the child, and why Part 6 should hold only what the ride needs.

What to write on the car seat line

The seat line should state the type, the model, and the child’s size, so dispatch can tell the family which seat to bring. The American Academy of Pediatrics gives the points a parent needs (page updated April 16, 2026):

• Back seat for everyone under 13. All children younger than 13 should ride in the back seat.
• Rear-facing as long as the seat allows. Infants and toddlers stay rear-facing until they reach the highest weight or height the seat’s maker allows.
• Booster until the belt fits. Children who outgrow a harness seat use a belt-positioning booster until the seat belt fits, typically around 4 feet 9 inches tall and between 8 and 12 years old.
• Special needs. A child with special health care needs may use a travel vest or a seat with a recline feature. The AAP points families to certified child passenger safety technicians, some with special-needs training, through the National Child Passenger Safety Certification list at 877-366-8154.

Who brings the seat depends on the program. Virginia’s handbook lists supplying the right car or booster seat for a child as a member responsibility. Georgia, Texas, Oregon, and Rhode Island handle it differently, and the children guide sets them side by side.

Filing it and keeping it current

Keep the signed form with the child’s rider profile and note it on each standing order so the next dispatcher sees it. Review it:

1. At the start of each school year or therapy series.
2. Whenever an adult on the form changes, because a changed adult needs a new signature, not a crossed-out line.
3. When the child passes a program’s age line, such as 13 in Virginia, since the rules for riding alone change.

Do not add a liability waiver line to this page. Keep the form’s one job, consent and instructions, and see liability waivers for NEMT riders for the separate question. Keep the form for as long as you keep the child’s trip records; the record retention schedule lists the usual periods.

Children’s rides in HealthRide

Escorts and extra passengers take seats on the trip in HealthRide, so the van that is assigned can carry everyone the form lists. The driver app captures a signature on screen, so the adult who takes the child can sign at the door. A parent waiting at the door can follow the driver’s arrival from a text link. See the driver app.