Sample Child Transportation Form
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1Livingston County Schools
Student’s Name_____________________________Grade_________Homeroom___________________
Bus Number_______________Pickup Number_____________Parking Number__________________
Please list below the names of people allowed to pick up your child and/or make transportation changes by note or phone.
Do not list numbers that are out of service, disconnected, or that do not accept incoming calls. Failure to make contact, in
case of an emergency, may result in being reported to Livingston County Bureau of Social Services.
List in the order you wish them to be contacted starting with parents/guardians in which the students live with.
Please circle 1-Pickup only 2-Phone Contact only 3-Transportation changes only 4-All
Name_________________________________Relationship_________________
Date Added_______Date Removed_____
Home Phone_________________ Cell Phone______________ Work Phone____________
1 2 3 4
Name_________________________________Relationship_________________
Date Added_______Date Removed_____
Home Phone_________________ Cell Phone______________ Work Phone____________
1 2 3 4
Name_________________________________Relationship_________________
Date Added_______Date Removed_____
Home Phone_________________ Cell Phone______________ Work Phone____________
1 2 3 4
Name_________________________________Relationship_________________
Date Added_______Date Removed_____
Home Phone_________________ Cell Phone______________ Work Phone____________
1 2 3 4
Name_________________________________Relationship_________________
Date Added_______Date Removed_____
Home Phone_________________ Cell Phone______________
Work Phone____________
1 2 3 4
Name_________________________________Relationship_________________
Date Added_______Date Removed_____
Home Phone_________________ Cell Phone______________ Work Phone____________
1 2 3 4
Name_________________________________Relationship_________________
Date Added_______Date Removed_____
Home Phone_________________ Cell Phone______________ Work Phone____________
1 2 3 4
Name_________________________________Relationship_________________
Date Added_______Date Removed_____
Home Phone_________________ Cell Phone______________
Work Phone____________
1 2 3 4
Name_________________________________Relationship_________________
Date Added_______Date Removed_____
Home Phone_________________ Cell Phone______________
Work Phone____________
1 2 3 4
I hereby authorize the contacts listed above to pick up my child from school, to be contacted in case of
emergency, and/or make transportation changes by note or phone.
______________________________________
__________________________________
______________
Name (Parent/Guardian)
Relationship
Date
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