3541 Appendix A
CHILD CARE AUTHORIZATION
I_____________________________ hereby authorize the Bristol Board of
(Parent or Guardians name)
Education to Pick up and/or Drop off my child at the following child care provider.
Student:
School:
Grade:
Parent/Guardian Contact #:
Child Care Provider's Name:
Child Care Provider Address:
Child Care Provider's PHONE NUMBER: ________________________________________
DAYS ATTENDING DAY CARE: ___ MON ___TUES ___WED ___ THUR ___ FRI
PICKUP [a.m.] Address:
DROP OFF [p.m.]Address:
EFFECTIVE DATE: _________________
SCHOOL YEAR_____________
I understand that the pick up and/or drop off address MUST BE ON AN EXISTING BUS
ROUTE for the school year and MUST BE IN MY CHILD'S PUBLIC SCHOOL
ATTENDANCE AREA. I will accept full responsibility for my child when he /she is at this
address.
Please submit this authorization form to the main office at your child's school, and allow 48
hours in change of transportation to take effect.
Any changes to this plan must be made in writing and submitted to the school principal who will
forward it to the Transportation Coordinator.
_______________________________________________________
______________
______
SIGNATURE OF PARENT OR
GUARDIAN
DATE
THIS FORM MUST BE COMPLETED ON AN ANNUAL BASIS, FOR
AUTHORIZATION TO CONTINUE FROM ONE YEAR TO THE NEXT.