CENTRAL DAUPHIN SCHOOL DISTRICT TRANSPORTATION DEPARTMENT

714 RUTHERFORD ROAD HARRISBURG, PA 17109

Fax (717) 214-1887

REQUEST FOR CHILD CARE PROVIDER

Trans. (Revised 3/12)

Student Name____________________________________________________ Address____________________________________ Zip ________________ School_______________________________________Grade_____________ Home Phone____________________________________________________ Care Provider Name______________________________________________ Care Provider Address____________________________________________ Phone Number____________________ (Required) AM Pickup □ PM Drop off □ Parent Signature____________________________________________ Date___________________________ The child must continue to use the assigned stop until notified that the change has been approved and arranged.

_____________________________________________________________ For Transportation Use Only Approved: Yes □

No □ Route Specialist:___________________________________________________ Date________________________ Comments_____________________________________________________________________________________ ______________________________________________________________________________________________

To School From School Bus No. _____________________ Bus No. ______________________ Stop Name___________________ Stop Name ____________________ Time________________________ Time __________________________