Alternate Pickup/Drop-Off Request Form

I would like to

Student's Full Name

First NameLast Name

Student's ID Number

If unknown, please contact your child’s school.

Student's Date of Birth

Student's School

Principal Email

example@example.com

Grade

Session

Does your child receive specialized transportation? (For example, door to door, wheelchair)

Type of Request

Parent/Guardian Name

First NameLast Name

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Current Home Address (on file with district)

Street Address

CityState / ProvincePostal / Zip CodeCountry

Parent/Guardian Email Address

example@example.com

Requested Pickup Location

Is the pickup location a residential address or a center/program?

Pickup Address

Enter the name of the person or location (e.g., Babysitter, Daycare, Program)

Street Address

CityState / ProvincePostal / Zip CodeCountry

Name of Person Responsible at Alternate Location

Phone Number at Alternate Location

Please enter a valid phone number.Format: (000) 000-0000.

Requested Drop-Off Location

Drop-off Address

Enter the name of the person or location (e.g., Babysitter, Daycare, Program)

Street Address

CityState / ProvincePostal / Zip CodeCountry

Is the drop-off location a residential address or a center/program?

Please identify the primary reason for requesting an alternate pickup/drop-off location:

By signing below, I acknowledge and understand that:

I am requesting transportation to and/or from a location other than the student’s primary/home address on file with the district.
Submission of this form does not guarantee approval or create an entitlement to transportation to or from the requested alternate location.
If approved, the alternate location must be used consistently five (5) days per week, Monday through Friday. Different pickup or drop-off locations may not be requested or used on different days.
An approved alternate location may not be changed without submitting a new request and receiving district approval before the change takes effect.
Approval is subject to district review, including transportation routing, capacity, scheduling, safety, operational considerations, and applicable district policies and procedures.
The alternate arrangement may not begin until I receive written confirmation of approval from the district. Until then, the student’s existing approved transportation arrangement will remain in effect.
Any approval applies only to the specific location, schedule, and dates stated in the district’s written approval.
Alternate transportation arrangements must be requested annually and do not automatically carry over to the following school year.
I will notify the district if the circumstances supporting this request change or the alternate location is no longer needed.
I understand that by requesting transportation to an alternate location, I am responsible for ensuring that the alternate location is appropriate and that an authorized adult is available to receive the student when required. To the extent permitted by law, I release and hold harmless the district, its employees, and agents from claims arising solely from my selection or use of the requested alternate location, except to the extent caused by the district’s negligence, misconduct, or other liability imposed by law.
I certify that the information provided on this form is accurate and complete.

Parent/Guardian Signature

Alternate Pickup/Drop-Off Request Form

Transportation Location