X hits on this document

13 views

0 shares

0 downloads

0 comments

6 / 6

Pleasant Hill R-III School District Summer School

DURHAM SCHOOL SERVICES BUS INFORMATION FORM

Student Name

____________________________________________________________________

(First)

(Middle Initial)

(Last)

Grade ______________

Birth Date

________________

Age __________

Address

_________________________________________________________

City ____________________________________________

State _______ Zip ___________

Home Phone _____________________

Emergency Contact

________________________________

Emerg. Phone

_______________________

Medical Problems/Allergies______________________________________________________________________ (This information will be kept confidential)

Parent(s) Name(s) ________________________________________________________________________

Parent’s Place of Employment

___________________________

Work Phone

__________________________

Bus #

____________

Pick-Up Address _____________________________________

Bus #

____________

Drop-Off Address

____________________________________

****Any other special instructions or information may be written on the bottom of this page****

PLEASE RETURN TO YOUR CHILD’S SCHOOL OR TO PLEASANT HILL MIDDLE SCHOOL ATTENTION: KAREN TARPENNING

1301

MYRTLE

PLEASANT HILL,

MO

64080.

Fax

816-987-2017

BY FRIDAY, APRIL 30TH

Document info
Document views13
Page views13
Page last viewedSat Dec 03 23:17:02 UTC 2016
Pages6
Paragraphs180
Words2102

Comments