NORTHERN POTTER SCHOOL DISTRICT

Bus Change Request Form

745 NORTHERN POTTER ROAD, ULYSSES, PA 16948
Mrs. SUSAN AMIDON, Assistant Transportation Director, (814) 848-7506

2019-2020 School Year

PLEASE ALLOW 2 SCHOOL DAYS for PROCESSING!

In order to utilize school bus transportation, the following regulations apply:

1. The child/children must be eligible for bus transportation.

(Definition: The student's residence to school must be at least 1.5 miles for grades K4-6 or 2 miles for grades 7-12 or be located on "Penn DOT" designated hazardous roads.)

2. The bus assignment is for one day only.  Requests will not be honored for partial weeks or every other week. *See Joint / Shared Custody Transportation Request Form for alternate bus arrangements.  ALL alternate bus transportation requests must be pre-approved.

          3.      Bus assignments are determined by the student's primary address and students will be transported to/from this location or the designated stop

for this location.

PURPOSE OF REQUEST:                 □  New  Bus Rider                        □  Change  (allow 2 days processing time)

STUDENT NAME(S)                                                        SCHOOL            GRADE

1. _______________________________________   _____________________________________  __________

2. _______________________________________   _____________________________________  __________

3. _______________________________________   _____________________________________  __________

4. _______________________________________   _____________________________________  __________

5. _______________________________________   _____________________________________  __________

State reason for bus change: _________________________________________________________________

_________________________________________________________________________________________

 Parent/Guardian's Phone Number:   __________________________________ Parent email: _________________________________________________________           

Parent/Guardian's Signature _______________________________________________________________________   Date ________________________________                

Bus STOP Request: (Please provide enough information so that we understand where you want your child(ren) dropped off.  Must be a designated bus

stop___________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

Parents/Guardians will receive notification of student's bus assignment via phone call, US Mail, or Email.

***********************************************************************

TRANSPORTATION SERVICES USE ONLY:

    □  AM        □ PM        BUS #         STOP        LOCATION:          New Stop: □ AM □ PM

    □  AM        □ PM        BUS #         STOP        LOCATION:          □ Hazardous Route

     □ Emergency Request Denied Reason: ___________________________________________________________________   □ Non-Reimbursable

Parent Notified: □ Phone  □ US Mail : □  Email Date  by: ________________________________(initials and date)