City of Big Rapids Dial-A-Ride Public Transit System Standing Call Service Request - Child

Passenger Name

Pickup Days of the Week (Please select all that apply):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Service Begin Date and Time

Service End Date:

Pickup Location

Destination Location

Passenger Age:

Passenger School Grade:

Can child be dropped off without seeing an adult?

Yes

Parent or Guardian Information

What is your relationship to the passenger?

Parent

Guardian

Parent or Guardian Name:

Parent or Guardian Address

Parent or Guardian Home Telephone Number:

Parent or Guardian Email Address:

Daycare Provider Name

Daycare Provider Phone Number

Employer Name

Employer Phone Number

Office use only: Transportation To/From Dial-A-Ride office (___)

Date: ________________

Books of Tickets Sold at Sale Price:_____________

Parent or Guardian Must Sign

Bus Safety Agreement

Passenger Name

I, the parent or guardian of the passenger listed in this agreement, acknowledge that I have received, read and understand the School Passenger Rules and Regulations issued by the City of Big Rapids Dial-A-Ride and agree to abide by the same. I understand that riding the Dial-A-Ride bus is a privilege which can be denied. I agree and understand that our children's safety on the bus is extremely important to Dial-A-Ride and to me. I will cooperate with Big Rapids Dial-A-Ride transit system to see that the highest degree of safety is maintained at all times.

Required Parent or Guardian Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.