RONDOUT VALLEY CENTRAL SCHOOL DISTRICT TRANSPORTATION DEPARTMENT

Name of Pupil
A request must be completed for each child
DOB

MonthDayYear
Date
Student Ethnicity (choose one)

I - American Indian or Native AmericaW - WhiteB - Black or African AmericanP - Native American or other Pacific IslanderH - Hispanic or LatinoA - Asian
Street Address: NO POST OFFICE BOX NUMBERS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different than street address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
RESIDENCY INFORMATION - (PLEASE CHOOSE ONE)

Both ParentsFatherMotherLegal GuardianStep-ParentRelative (enter name in box)
Primary Custodial Parent/Guardian
Home Number
Please enter a valid phone number.
Cell
Please enter a valid phone number.
Secondary Custodial Parent/Guardian (if applicable)
Home Number
Please enter a valid phone number.
Cell
Please enter a valid phone number.
Name of PRIVATE/PAROCHIAL School to which transportation is requested:
Grade
List two local relatives or neighbors to contact if you are not available.

I give permission for these people to pick up my child and assume temporary care if necessary if I cannot be reached:
1) Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
2) Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
PLEASE BE ADVISED THAT RONDOUT VALLEY CSD WILL NOT TRANSPORT TO PRIVATE/PAROCHIAL SCHOOLS ON DAYS WHEN OUR DISTRICT IS CLOSED
For children entering KINDERGARTEN, a Rondout Valley Central School District registration packet must also be completed. Child must be FIVE (5) years of age by December 1st to enter Kindergarten.
SIGNATURE OF PARENT/GUARDIAN

Clear
DATE

MonthDayYear
Date
PLEASE RETURN COMPLETED FORM BEFORE APRIL 1st TO:

Rondout Valley Central School District, Transportation Department, PO Box 9, Accord, New York 12404

Phone: (845) 687-2400 x4815 or Fax: (845) 377-2297

Email: transportation@rondout.k12.ny.us or aholden@rondout.k12.ny.us
Should be Empty:

PLEASE BE ADVISED THAT RONDOUT VALLEY CSD WILL NOT TRANSPORT TO PRIVATE/PAROCHIAL SCHOOLS ON DAYS WHEN OUR DISTRICT IS CLOSED