MID COLUMBIA BUS COMPANY
REQUEST FOR TRANSPORTATION SERVICES-NEED SEPARATE FORM FOR EACH STUDENT
School *
AM Route # (if known)
Your answer
PM Route # (if known)
Your answer
Student Name *
Your answer
Grade *
Street Address *
Address and City
Your answer
Mailing Address *
Your answer
Contact Phone Number *
Your answer
Secondary Phone Number
Your answer
Route Times *
Reason for Request *
Request New Stop (give address)
Your answer
Check which days student will ride *
Required
Parent/Guardian's Name *
Your answer
Parent/Guardian's Email *
Your answer
Release Information - Kindergarten Only
Student can be released to the following
Person #1
Name #1
Your answer
Phone #1
Your answer
Person #2
Name #2
Your answer
Phone # 2
Your answer
Person #3
Name #3
Your answer
Phone #3
Your answer
Person #4
Name #4
Your answer
Phone # 4
Your answer
Kindergarten students will NOT be dropped off without an authorized adult present.
FOR MORE INFORMATION CONTACT: Shelly Polk, Location Manager
Phone: 503-767-2480 Fax: 503-767-2482
Email: rpolk@midcobus.com
School Website: www.nsantiam.k12.or.us
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