Student Child Care Information
Please fill out this form completely, including the complete address information for the child care provider. Information provided will be considered confidential and will be used for internal school district purposes only. If you have questions or concerns, please call the District 191 Transportation Services office at (952) 707-2067 or (952) 707-2069.
Student/Parent Information
Please fill out the following information about your family, listing the students who will need to be picked up from or dropped off at child care or another alternate address.
School of Attendance *
School Year *
1. Student Name *
Your answer
Grade *
Your answer
2. Student Name
Your answer
Grade
Your answer
3. Student Name
Your answer
Grade
Your answer
4. Student Name
Your answer
Grade
Your answer
Head of Household
Parent/Guardian Name *
Your answer
Home Address & Phone Number
Home Street Address *
Your answer
City *
Your answer
State
Zip Code *
Your answer
Home/Cell Phone *
Your answer
Work Phone
Your answer
Name of Child Care Provider (Person or Company)
Please provide information about the alternate address for your child care provider and pick-up or drop-off needs.
Child Care Provider Name *
Your answer
Provider Street Address *
Your answer
Provider City, State, Zip *
Your answer
Provider Phone *
Your answer
Child Care Transportation Needs *
I realize it is my responsibility to bring my child to and from this alternative site. *
Required
Signed *
Type name of acknoledging legal parent / guardian
Your answer
If you have questions, contact the Transportation Department at: *
Submit
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