CHILD CARE INFORMATION

Your school needs the following information for transportation and other important records. If your youngster will be served by a child care provider at an address other than your home during 2004-2005, please complete and return this form to your child's assigned school. Without this form, we will assume that your child will be picked up and dropped off at his/her home address. Besides updating this form annually, you must also notify the school of changes that occur over the summer or during the school year. Changes must be in writing.

Child's Name:______________________Circle one: new student, current student

Circle one- Student Attending: LMHS, LMJHS, LMI, Butlerville, Maineville, Morrow

Address:_________________________ Home Phone:________________

City:______________________________

Grade_____________ If Kindergarten: Circle: AM or PM

Mother's Name:_______________ Employer_______________

Work Phone__________

Father's Name:_______________ Employer_______________

Work Phone__________

Child Care Provider_______________ Date information is effective__________

Address______________________________ Phone_______________

Subdivision Name if Applicable:_________________________

PLEASE COMPLETE FOR TRANSPORTATION INFORMATION. CHILDREN MUST GO TO AND FROM A CHILD CARE GIVER IN THEIR SAME SCHOOL ATTENDANCE ZONE.

My child will be picked up at the child care provider on the following days:

Mon_______ Tues_______ Wed________ Thurs________ Fri_______

My child will be dropped off at the child care provider on the following days:

Mon_______ Tues_______ Wed________ Thurs________ Fri_______

Additional Information:

____________________________________________________________

Parents Signature______________________________________________

School office: Please fax copy to transportation immediately.

Last update: Thursday, August 26, 2004 at 5:27:34 AM.

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