Daycare Request Form
(or Alternative Pick-up/Drop-off Location)

Important: Use this form only if your child is using daycare and needs to ride the bus between the daycare location and school.

Please also use this form if your child is attending Home Base.

District 284 Transportation Policy allows transportation services to and from a daycare site under the following guidelines:

1. The daycare location must be within the attendance are of your child's school.
2. The child must always be picked up or dropped off at the same daycare location.
3. Arrangements for busing must be made in writing through the Transportation Department.

Student Information
Student's First Name *
Your answer
Student's Last Name *
Your answer
School *
Your answer
Grade *
Head of Household
Last Name *
Your answer
First Name *
Your answer
Middle Name
Your answer
Home Address & Phone Number
Street Address *
Your answer
Apt. #
Your answer
City *
Your answer
Zip *
Your answer
Phone *
Your answer
E-mail Address *
Your answer
Name of Daycare Provider (Person or Company)
Last Name *
Your answer
First Name *
Your answer
Middle Name
Your answer
Daycare Provider Address and Phone #
Address *
Your answer
Apt. #
Your answer
City *
Your answer
Zip *
Your answer
Phone *
Your answer
Daycare Transportation Needs *
Beginning Date *
Your answer
Ending Date *
Your answer
I realize it is my responsibility to bring my child to and from this daycare site. I do hereby agree to save the School District harmless for any damage resulting from its granting this request. *
Required
Signed *
Type name of acknowledging legal parent / guardian.
Your answer
Date *
Your answer
Submit
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