CA B IN ET FOR H EA LTH A ND FA M ILY SER VIC ES

D epart me nt f or C ommu nity B as ed Serv ic es

D ivision of Pr ot ect ion and Perman ency

Andy Beshear 275 East Main Street, 3E-A Eric C. Friedlander

Governor Frankfort, KY 40621 Secretary
502-564-6852
502-564-4653
www.chfs.ky.gov/agencies/dcbs

Authorization for out of state travel for a foster child during COVID-19*
(Complete a separate form for each child)

Section I: Completed by Foster Parent

Child’s Last Name: Child’s First Name: Child’s DOB:

Foster Parent’s Last Name: Foster Parent’s First Name

Foster Parent’s contact during travel: Secondary contact during travel:

Name: ______________________________________ Phone: _____________________________________

Destination of Travel: (Location Name and Address) Duration of travel:

From: ___________________(date) to ______________________ (date)

Purpose of Travel:

How will healthy social distancing, masks (if age appropriate), or other measures be utilized to ensure children aren’t put at greater risk for illness while
traveling?

Does the child have any health conditions that would place them at greater risk? If yes, Explain

Section II: Completed by Worker

Type of Custody: Status of Parental Rights: Has permission been obtained from the birth parents if the child is in the temporary custody
Temporary Parental Rights intact of the Cabinet?
TPR has occurred
Committed Yes No
If no, please explain: ________________________________________

_____
Foster Parent (Date) Worker (Date) Reviewed by SRA/designee (Date)

*This form is for use during the state of emergency

Kentucky.gov An Equal Opportunity Employer M/F/D