Little Cruisers Transportation Service Request

Transportation Service Request

Please fill out form completely.
Member Type Request*
Rates are Round-trip based and does not include appicable taxes
Requested Days*

MondayTuesdayWednesdayThursdayFriday
Requested Service*

Home → DaycareDaycare → HomeHome → SchoolSchool → HomeSchool → After school programOther
Name of School/Daycare*
Type of School*

DaycarePre-KElementary SchoolMiddle SchoolHigh SchoolIntermediate SchoolOther
Current Child's Grade*
If still in Daycare, just put "DC"or "Daycare"
Requested Pick up Time*

Hour Minutes

AM/PM Option
Requested Drop off Time*

Hour Minutes

AM/PM Option
Initial Pick Up Address*

Street Address

Street Address Line 2

CityState

Zip Code
Drop Off Pick Up Address*

Street Address

Street Address Line 2

CityState

Zip Code
Child's Full Name*

First NameMiddle InitialLast NameSuffix
Child's Birth Date*

MonthDayYear
Primary Parent's Full Name*

First NameMiddle InitialLast NameSuffix
Primary Parent Parent's Birth Date*

MonthDayYear
Primary Parent's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the Child has the same home address as the Primary Parent?*

YesNoShared CustodyOther
Primary Parent's Phone Number*
Please enter a valid phone number.
Primary Parent's Email*
example@example.com
Relations to Child*

MotherFatherStep-MotherStep-FatherLegal GuardianGrandmotherGrandfatherFoster ParentOther
Secondary Parent's Full Name

First NameMiddle InitialLast NameSuffix
Secondary Parent Parent's Birth Date

MonthDayYear
Secondary Parent's Phone Number
Please enter a valid phone number.
Secondary Parent's Email
example@example.com
Secondary Parent's Relations to Child

MotherFatherStep-MotherStep-FatherLegal GuardianGrandmotherGrandfatherFoster ParentOther
Does the Secondary Parent has the same home address as the Child?

YesNoShared CustodyOther
Child's Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Do your child has any Food Allergies/Medication conditions that we should be aware of?*

YesNo
If yes to Food Allergies/Medication conditions please list.
Example: Nuts, Dairy, Diabetic, Anxiety, ADHD
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Relations to Child*

MotherFatherStep-MotherStep-FatherLegal GuardianGrandmotherGrandfatherFoster ParentOther
Emergency Contact Address

Street Address

Street Address Line 2

CityState

Zip Code
How did you hear about Little Cruisers?*

FriendOnlineFamilyRepFlyerCo-workerOther
Will you be willing to recommend us?

YesNoMaybe

Please give reference of any 2 or more parents whom you feel:

	First & Last Name	Contact Number
1
2
3

Additional Requests/Concerns or Comments?
Thank you for taking the time to fill out this form. We will be in contact to follow up with you in 1-2 business days!
Should be Empty:

Transportation Service Request

Thank you for taking the time to fill out this form. We will be in contact to follow up with you in 1-2 business days!