Bus Program

Where we can make a difference

Bus Program Reservation Form

2018 - 2019 Academic Year

* indicates required field

Student Name: *

Grade: *

Address: *

City: *

Postal Code: *

Res Phone:

Bus. Phone:

Cell Phone:

Emergency Contact:

Please indicate the type of service required: *

AM only PM only AM & PM

The nearest intersection to my home is: *

The nearest MAJOR intersection to my home is: *

Payment Plan: *

Advanced Monthly

Payment Method *

Cheque VISA/MC

I am the parent/legal Guardian and authorized person over the student mentioned above.

I authorize the following to pick up/drop off the student mentioned above from the school bus:

Name(1):

Relationship:

Name(2):

Relationship:

Name(3):

Relationship:

Does your child have a medical condition? *

Yes No

If yes, please indicate:

Health Card Number: *

Expiration Date: *

Your name: *

Your E-mail address *

Confirmation Email