Breck Road Transportation Consent Form

Van Rider Permission

School Year 25-26
Name of Student:

First NameSurname
Student attend's the following school
Student Mobile No. (in order to communicate about pick up):
Student allergies:
I give permission for the student listed above to use the van service provided by Music Resource Center for transportation to Music Resource Center (105 Ridge Street, Charlottesville, VA 22902) for the 2025-2026 School Year.
Name of Parent/Legal Guardian:

First NameSurname
Parent/Legal Guardian Mobile No.:
Parent/Legal Guardian email:
example@example.com
I understand that:
- The van provides transportation to MRC only. It is the responsibility of the member’s guardian to arrange pick up from MRC by 7 PM.
- The van will be running immediately after school and it is the responsibility of the member to arrive promptly for pickup.
  - Mondays- Monticello HS
  - Tuesdays- Charlottesville HS
  - Wednesdays- Charlottesville Middle School
  - Thursdays- Albemarle HS
- Members are expected to adhere to the same rules of conduct while on the bus as if they were at MRC.
- Taking a seat on the van is a privilege that reduces availability for others. Inconsistent ridership or disruptive behavior while riding will result in the loss of this previlege.
  There may be cancellations of the service or individual pick-ups /drop-offs due to availability, capacity, etc. MRC will make every effort to notify of the situations well in advance.
Contact MRC at 434-979-5478 or

Alice Fox at 202-341-3764 with any questions or issues day of transportation.
Date:

DayMonthYear
Signature of Parent/Legal Guardian:
Should be Empty:

Van Rider Permission