Butte School District

Ineligible Transportee Application For Transportation

Student’s Address:______________________________________________________________
(Last) (First) (Middle)

School:________________________________________Grade:__________________________

Parents:

Father’s Name: __________________________         Work Phone: _______________________

Mother’s Name: ______________________________ Work Phone:_______________________

Student’s Address: _____________________________________________________________

Home Phone: ________________________________Emergency Phone: __________________

OFFICIAL USE ONLY

Pick –Up Bus Stop: __________________

Student’s Address:______________________________________________________________
(Last) (First) (Middle)

School:________________________________________Grade:__________________________

Parents:

Father’s Name: __________________________         Work Phone: _______________________

Mother’s Name: ______________________________ Work Phone:_______________________

Student’s Address: _____________________________________________________________

Home Phone: ________________________________Emergency Phone: __________________

OFFICIAL USE ONLY

Pick –Up Bus Stop: __________________

Time: ___________________________Bus Number: ____________________

Drop-Off Bus Stop: ___________________________________________________________

Time: ___________________________Bus Number: ____________________

Bus Pass Number: _____________________________Date Purchased: __________________

Amount Paid: $___________________

(COPY OF THIS FORM TO BE USED AS RECEIPT FOR MONEY PAID.)