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Summer School MidCo Bus Reg Form
REQUEST FOR TRANSPORTATION SERVICES-NEED SEPARATE FORM FOR EACH STUDENT
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* Indicates required question
School
*
Mari-Linn School
Sublimity School
Stayton Elementary School
Stayton Middle/Intermediate School
Stayton High School
AM Route # (if known)
Your answer
PM Route # (if known)
Your answer
Student Name
*
Your answer
Grade
*
Choose
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Street Address
*
Address and City
Your answer
Mailing Address
*
Your answer
Contact Phone Number
*
Your answer
Secondary Phone Number
Your answer
Route Times
*
AM
PM
BOTH
Other:
Request New Stop (give address)
Your answer
Check which days student will ride
*
Monday
Tuesday
Wednesday
Thursday
Friday
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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