A 4-page Word form to authorize and plan a client’s community outing with a caregiver, one time or under a standing (blanket) approval.

For USA non-medical home care agency owners and supervisors who arrange outings, errands, and activities for clients. Plus 1 agency instructions page to remove before use.

What’s included

1. Page 1: section 1 client information, section 2 authorization type (one-time or blanket), section 3 outing details, section 4 transportation method and driver, and section 5 assigned caregiver / companion
2. Page 2: section 6 outing-relevant trip safety considerations, section 7 emergency contacts, check-in, and missing-client steps, and section 8 client money and purchases
3. Page 3: section 9 consent and acknowledgments (including optional photo / media consent), signatures, and the trip return record
4. Page 4: blanket outing trip log and an optional Agency Use Only supervisor spot-check
5. Agency instructions page, to remove before use

Add your logo and name

1. Open the Word file and replace the Your Logo Here box with your logo.
2. Replace Agency Name in the letterhead; the form body says “the Agency,” so no other name edits are needed.
3. Replace the Street Address, City, State ZIP line and the Phone, Email, Website line with your details.
4. Fill in your on-call and emergency phone fields, set the letterhead text to black, delete the instructions page, and save.

Customizable template, not legal advice; check your state’s requirements. Not a license to operate, not HIPAA software, and no medical claims. Vehicle risk is not covered by this form; handle driving terms separately under your own policies.