SCHOOL YEAR 2019-2020 NORTHERN POTTER SCHOOL DISTRICT

JOINT/SHARED CUSTODY or ALTERNATE Drop-Off Location TRANSPORTATION REQUEST FORM

This Request form is to be used when transportation is a Joint/Shared Custody situation. That is, both parents living in separate households, living within the district and are living in the attending school boundary in which the student attends. Transportation is NOT provided to the parent living outside of the attending school boundary or district. This form can also be used for permanently separate morning and afternoon locations- that is when the morning and afternoon addresses are different.

Students: K4-12 grades pickup and/or drop-off locations may be two different custody household locations with the understanding the student is solely responsible for boarding the correct bus.

This request EXPIRES at the end of EACH school year. The form is to be submitted each year before the end of JULY. Submit this form to the Northern Potter School District Office and allow one school week  for processing. If submitted during the school year, the school will contact the parent with the start date and bus information once the request has been approved and the transportation is in order.

Student Name:          Start Date:         

School Attending: Northern Potter School District                       Grade:                

Family 1:

Parent Name:        Home Phone:        Work Phone: ________________

Address:        

Family 2 or Location (Please state relationship to child if not a parent): _______________________________________

Parent Name:        Home Phone:        Work Phone: ________________

Address: ___________________________________________________________________________________

GRADE K4-12 - PICK UP STUDENT BUS STOP INFORMATION

BEFORE SCHOOL PICK UP LOCATION

Home         

BEFORE SCHOOL PICK UP LOCATION (if student will be using more than one household for busing)

Home         

GRADE K4-12 - DROP OFF STUDENT BUS STOP INFORMATION

AFTER SCHOOL DROP OFF LOCATION

Home Address                        

AFTER SCHOOL DROP OFF LOCATION (if student will be using more than one household for busing)

Home Address        

We agree and acknowledge the information on this form as correct.

  1. Parent/Guardian Signature                     Date __________

(Family #I)

  1. Parent/Guardian Signature                 Date __________

(Family #2)