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: _____________________________________________________ SCHOOL: _________________
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 I
f the location of the stop is inconsistent with Board policy.

____________________________________________________________________________________________________________
Signature (Parent/Legal Guardian)
Todays Date
Date to START

Date received in office_________________