Minnesota New Country School Elementary

REQUEST FOR TRANSPORTATION CHANGE

Complete and return this form to the Elementary Front Desk. Please print.
STUDENT'S NAME: _______________________________________________
GRADE:____________
TEACHER: _______________________________________
PRESENT BUS ROUTE: ____________________________
CHANGE TO BUS ROUTE: __________________________
REQUESTED DATE(S) OF CHANGE: _________________________________
REASON FOR CHANGE REQUEST: ___________________________________
_________________________________________________________________

PARENT/GUARDIAN NAME(S): ___________________________________________

HOME/STREET ADDRESS: ______________________________________________
DAYTIME PHONE NUMBER(S): ___________________________________________
EMAIL: _______________________________________________________________
PARENT/GUARDIAN SIGNATURE: ________________________________________
DATE: __________________

NAME OF PERSON/STUDENT STAYING WITH: ______________________________

HOME/STREET ADDRESS: ______________________________________________
PHONE NUMBER(S): ___________________________________________________

For Office Use Only:

OFFICE SIGNATURE:
DATE:
ADDRESS: 127 N. 8th Street, Henderson, MN 56044
FAX: 507-868-0074

PHONE: 507-868-0071

EMAIL: frontdesk@newcountryschool.com