Transportation Information Form

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TRANSPORTATION INFORMATION FORM
SCUSA Transportation
1000 N First Street, Suite 15
Albemarle NC 28001 (704) 986-3790 FAX: (704) 982-5735
Passenger Name _____________________________________________
Age __________ Weight __________Date of Birth___________
Address ____________________________________________________________Phone____________________
Parent/Guardian ___________________________________________
Passenger Lives with ___________________________________________
Emergency Contact __________________________________ Emergency Phone ___________________
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(This section to be filled in by SCUSA office)
Driver’s Name ______________________________ Driver’s Phone ______________________________
Approximate pickup time __________________ A.M. ________________________ P.M.
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For afterschool care, please fill out #1, #7, #8 and #9:
1.
Afterschool care Agency: _______________________________________________
Are there any special needs, assistance?: ______________________________________________________
__________________________________________________________________________________________
2.
Directions to passenger’s house (use street address, county road name and number, etc)
PLEASE BE SPECIFIC WITH NAMES & DIRECTIONS.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Is pickup/discharge different from above? _____ (yes) _____ (no). If yes is marked, please
include directions to pickup/discharge location.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Can passenger be dropped off at the end of the driveway if taken to the house? ____________ .
Should the driver wait/watch until passenger gets in the house? ___________. Can passenger
be left alone at home? ________________. If no, please list name/phone # of contact person to
notify.
__________________________________________________________________________________
3.
List any special assistance that the passenger may need. (Example: assistance getting in/out of
vehicle).
__________________________________________________________________________________
__________________________________________________________________________________

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