Merriam School Bus Pass Form

Revised Oct. 3, 2004.

Teacher: _____________________________ Room: ______ Date: ____/____/____

This form must be delivered to the school office at the beginning of the school day for which the change is effective, otherwise the student will be dismissed according to his/her usual dismissal procedure. Bus changes cannot be taken over the phone, except in an emergency to be determined by the school principal.

Note:s Bus 4 can no longer accept bus passes from children not ordinarily assigned to it (i.e., no visitor or play day passes).

Check one line which applies and fill out all other information thereafter.

_______________________________ has permission to ride Bus # _______ to
(Student name)

__________________________________. The student will be in the care of
(Bus stop location)

________________________________ who can be reached at
(Parent, guardian, daycare, etc.)

______________________.
(Phone #)

_________________________________________________
(Signature of parent/guardian requesting bus pass)

_________________________________________________
(Daytime Phone Number where you can be reached )


___________________________________________ (Signature of School Official)	______/______/_______ (Date)

	Permanent Change for every: (Circle days of week for change)
MON - TUES - WED - THURS - FRI

One Day Change for:	_________________	______/______/_______
	(Day of week)	(Date)