Student Name: ____________________________

Grade: ______________________________

Home Address: ____________________________________________________________________

Parent Phone: ______________________________

School Attending:  (circle one)

Name of Daycare Provider:  ________________________________________________________

Address of Daycare Provider: ________________________________________________________________

Student will be picked up before school at the Daycare Provider's address (above) on the following day(s):

Student will be dropped off after school at the Daycare Provider's address (above) on the following day(s):

Parent/Guardian Signature:  _______________________________________________________________

***Transportation to daycare arrangements will be allowed provided there is sufficient space on the bus and it does not cause the bus to deviate from its current route.  Daycare forms should be returned to the school secretary at your child's school.