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FAMILY BUS REGISTRATION

K-8 2016-2017 School Year


Parents Name

(Please Print)

Address

Telephone

Student #1 Name

Grade

Student #2 Name

Grade

Student #3 Name

Grade

Student #4 Name

Grade

Student #5 Name

Grade
Total Number of Students Riding the Bus

Choose One

Round Trip

1 Way AM

1 Way PM

Annual payments are due in the parish office by July 1, 2016


100 Harvey St., Washington, IL 61571

Option 1 Annual Payment

Ck#

Option 2 - 10 Month Plan

Option 3 - 12 Month Plan

Aug. 10 or 20, 2016 through May 10 or 20, 2017


Automatic Bank Withdrawal

Aug. 10 or 20, 2016 through July 10 or 20, 2017


Automatic Bank Withdrawal

Check#

BUS

Annual Bus

Check#

Daily per Child

10 Month Plan

12 Month Plan

$57.53
$28.82
$102.85
$51.50
$148.28
$74.14

$47.94
$24.02
$85.71
$42.92
$123.57
$61.78

based on 176 days

1 Child Round Trip


1 Child One Way*
2 Children Round Trip
2 Children One Way*
3 or more Round Trip
3 or more One Way *

$575.30
$288.20
$1,028.50
$515.00
$1,482.80
$741.40

$3.27
$1.64
$5.84
$2.93
$8.43
$4.21

Office Use
Route
February 11, 2016

Subdivision