Student's Full Name:

Student's HOME ADDRESS:

Date of Birth:

Race:

Gender:

Grade:

Teacher:

Please specify the morning and afternoon addresses for your child.

Please check your child’s mode of transportation and circle the route time(s).

If your child’s pick up and/or drop off is different from the home address please name the
daycare, babysitter and/or other:

Afternoon Address (if different from morning address):

Other Comments:

Student Health / Medical Concerns for the Driver:

Parent/Guardian:

Home Phone #

Cell Phone #

Work Phone #

Parent/Guardian:

Home Phone #

Cell Phone #

Work Phone #

Parent/Guardian's Signature

For Office Use Only

PM

Car Tag#

AM

Today's Date