Grade K & 1

This form is provided for those families who have a child in grade K or 1, who are unable to disembark the school bus at the end of the day without an approved adult present.

District

School

Grade

Student Last Name

Student First Name

Birth Date

GSACRD STUDENT ID#:

Parents/Guardians may provide below a maximum of 4 additional adults approved to pick their child up from the bus.

Last Name

First Name

Preferred Phone

Relationship

Last Name

First Name

Preferred Phone

Relationship

Last Name

First Name

Preferred Phone

Relationship

Last Name

First Name

Preferred Phone

Relationship

Submitted by

Last Name

First Name

Email