Transportation Form

Revised 11/25/2014

LOUDOUN COUNTY PUBLIC SCHOOLS

KINDERGARTEN STUDENT TRANSPORTATION FORM

This form is provided to facilitate establishing mid-day Kindergarten transportation. In order to establish bus routes, we need specific

information about pick-up and delivery points for your child. Use ONE form per student. Neatly PRINT all appropriate sections of this

form.

Special Notice: AM/PM session assignments will be determined by July 29, 2016 for the 2016-2017 school year and are decided by the

Transportation office in conjunction with school administration. Placement and transportation arrangements will be based on the student's

residence contained on this form which is due by June 14, 2016. Changes made after this date may result in parents being responsible for

transporting their child to or from the kindergarten program.

Specific request: AM or PM (Circle one) Note: You may request a specific session however, the parent acknowledges that bus

transportation may NOT be provided mid-day.

For Office Use Only

Original Request Date _______________

Revision Date ____________________

School: ____________________________________________________________________

Kindergartener’s Name: __________________________________________ ID#_________

Parent(s) Name: _____________________________________________________________

Home Address: _____________________________________________________________

(County Assigned House Number and Street)

_____________________________________________________________

(City)

Home Phone: _________________

Work Phone: ________________

Cell Phone: __________________

Additional Authorized Person/Escort to receive student (list all) ___________________________________________________________

______________________________________________________________________________________________________________

If you WILL be requesting mid-day Kindergarten transportation on an LCPS school bus, please complete Section 1 below. If you

WILL NOT be requesting mid-day Kindergarten transportation on an LCPS school bus, please complete Section 2 below.

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Section 1:

_____

My Kindergartner will ride a mid-day LCPS school bus to or from school from the home address above.*

NOTE: Students will be returned to the school if an Authorized Person/Escort is not present to receive

them at the mid-day or afternoon stop.

_____

My Kindergartner will ride a mid-day LCPS school bus to or from a day care provider or baby sitter in the

school’s attendance area.

Name of day care provider or baby sitter: ____________________________________________________

Address of day care provider or baby sitter: __________________________________________________

(County Assigned House Number and Street)

Phone number of day care provider or baby sitter: _____________________________________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Section 2:

_____

My Kindergartner WILL NOT ride a mid-day LCPS school bus to or from school, but will be transported

to/from school by:

_____ parent/guardian

_____day care provider

_____baby sitter.

Name of day care provider or baby sitter: ____________________________________________________

Phone number of day care provider or baby sitter: _____________________________________________

*Should the home or day care provider be within the school’s walking area, school bus transportation is only provided at mid-day to deliver

AM kindergarten students home or to transport PM kindergarten students to school.

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I understand this form is due by June 14, 2016, and it is the parent’s responsibility to immediately notify the local school if there are

any changes in the information listed above.

_______________________________________________________________

____________________________

(Parent’s Signature)

(Date)