2009-2010 Bus Registration Form

Childs Name: _______________________________________________________

Parents/Guardians Names: ____________________________________________

Childs Birthday: ________________________ Age: _________ Grade: _________

Child’s School: ________________________________

Address: ___________________________________________

              ___________________________________________

              ___________________________________________

Home Phone Number: ______________________________

Work Number: ___________________________

Cell Phone Number: _______________________

Emergency Contact Information:

Name: _________________________________                                                              Relationship to child: _______________________

Phone Number: ______________________ Cell Phone Number: ________________

Address: __________________________________

              __________________________________

I, ________________, give permission for my son/daughter to ride the bus to the Linnville Lighthouse After School Program. I will not hold St. John’s Lutheran Church or the After School Program responsible for any accidents that occur while my child is in attendance.

Parent Signature: _____________________________________ Date: _____________