VDSS MODEL FORM FDH

GENERAL PERMISSION FOR REGULARLY SCHEDULED TRIPS

(Required by Standards for Licensed Family Day Homes 22 VAC 40-111-980 A)

Childs Name


Routine Trip
Destination(s)




Mode of Transportation:

___ Walking

___ School bus

___ Public transportation

___ Provider vehicle ______________________________________
Name of Driver

___ Other vehicle ______________________________________
Name of Driver


I grant permission for my child to participate in the regularly scheduled trips
described above.

________________________________________________ _____________________
Parents Signature Date


032-05-0610-00-eng