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Student Transportation Request Form
Please complete all of the required sections below
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* Indicates required question
School Attending
*
Choose
Mount Clemens High School
Mount Clemens Middle School
Seminole Academy
M. L. King Academy
Date Student will Start School
*
MM
/
DD
/
YYYY
Student Name
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Grade
*
Choose
GSRP / ECSE
K
1
2
3
4
5
6
7
8
9
10
11
12
Student Home Address - Number, Street, Unit #
*
Your answer
Student Home Address - City
*
Your answer
Student Home Address - Zip Code
*
Your answer
Parents/Guardian #1 - Name
*
Your answer
Parents/Guardian #1 - Cell Phone
*
Format: 555-555-5555
Your answer
Parents/Guardian #1 - Email address
*
Your answer
Parents/Guardian #2 - Name
Your answer
Parents/Guardian #2 - Cell Phone
Format: 555-555-5555
Your answer
Parents/Guardian #2 - Email address
Your answer
Emergency Contact/Pickup #1 - Name
Your answer
Emergency Contact/Pickup #1 - Relation to Student
Your answer
Emergency Contact/Pickup #1 - Phone
Format: 555-555-5555
Your answer
Emergency Contact/Pickup #1 - Days/Times On Call
Your answer
Emergency Contact/Pickup #2 - Name
Your answer
Emergency Contact/Pickup #2 - Relation to Student
Your answer
Emergency Contact/Pickup #2 - Phone
Format: 555-555-5555
Your answer
Emergency Contact/Pickup #2 - Days/Times On Call
Your answer
DO NOT release student to these individuals
Your answer
Which of the following applies to your transportation request
*
New enrollee into the district
Recently moved within the district
Re-enrolling for transportation
Did you receive transportation last school year at this same home address?
*
Yes
No
If yes, what bus stop did you use last school year?
Your answer
Will you have siblings riding the bus together?
*
If yes please also submit a separate request for each student.
Yes
No
Acceptance of Transportation Guidelines
I agree that if my child is eligible for transportation, I will explain the bus rules to my child(ren). If they fail to abide by the rules or disobey the driver/aide’s instructions, they will be subject to a write up and discipline that can include suspension from bus privileges for a period of time based on school policy, and I agree to honor the suspension.
Please note – new transportation requests may take up to 2-3 business days for processing before starting.
Do you agree to the transportation guidelines above?
*
I agree
Required
Name of individual completing this form and agreeing to guidelines
*
Your answer
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