Transportation and After School Form

Middletown Christian School
70 Highland Avenue Middletown, NY 10940 Phone: (845) 343-3775 Fax: (845) 343-6633
TRANSPORTATION & AFTER SCHOOL INFORMATION
Student's Name
Grade
Please indicate your child's after school transportation arrangements (Write Yes or No)
1. My child is to wait at school until his/her ride arrives.
2. My child will ride the School Bus daily.
If you answered YES, please indicate the School District below
School District
3. My child may walk/ride a bicycle after dismissal.
I understand that the school provides no student supervision past 2:45pm Monday through Thursday and 1:30pm on Friday and early dismissal days unless the student is in the After School Program.

All students who are not under the supervision of the After School Program and remain in or around the building will be charged $5.00 from 16 Minutes to 45 Minutes. After 45 Minutes the charge will be $10 per 1/2 hour, per student.

Further, I understand that if the arrangements I have noted above change, I will notify the teacher.
Authorized Individuals

Please list any other authorized individuals to pick up your child:
1. Name
1a. Relationship to student
1b. Phone Number
2. Name
2a. Relationship to student
2b. Phone number
Parent's Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Middletown Christian School