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:
(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.)
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
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.
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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)