AM BUS #___T___PM BUS#___T___

(Office use only)

Transportation Office 330.296.6828

Fax 330.297.4152

RAVENNA SCHOOL DISTRICT ALTERNATE BUS STOP FORM

PLEASE PRINT

STUDENT LEGAL NAME: ___________________________________________________GRADE:__________

HOME ADDRESS: ___________________________________________________________________________
HOUSE#

STREET

PARENT/GUARDIAN NAME: _________________________________HOME PHONE:__________________

WORK PHONE: ___________________________________CELL PHONE:______________________________
PLEASE CHOOSE ONLY ONE OF THE FOLLOWING:

Pick-up will be at the following daycare/sitter with drop-off at HOME

DAYCARE/SITTER NAME: _________________________________Phone:_________________________
DAYCARE/SITTER ADDRESS: ____________________________________________________________
DAYCARE/SITTER AUTHORIZED SIGNATURE: ____________________________________________

Pick-up will be at HOME with the drop-off at the following DAYCARE/SITTER

DAYCARE/SITTER NAME: ________________________________Phone:_________________________
DAYCARE/SITTER ADDRESS: ____________________________________________________________
DAYCARE/SITTER AUTHORIZED SIGNATURE: ____________________________________________

Pick-up AND drop-off at the following DAYCARE/SITTER

DAYCARE/SITTER NAME: ________________________________Phone:__________________________
DAYCARE/SITTER ADDRESS: ____________________________________________________________
DAYCARE/SITTER AUTHORIZED SIGNATURE: ____________________________________________

If approved, I understand that the child listed above will be picked up and dropped off at the requested above Alternate Stop Address
until I request, in writing, for this service to end. I understand the Ravenna Board of Education reserves the right to deny this request
if the location of the stop is inconsistent with Board policy.

_______________________________________________________________________________________________________
Signature (Parent/Legal Guardian)

Todays Date

Date to START

Date received in office_____________