LHA STUDENT TRANSPORTATION FORM

STUDENT DRIVERS + AUTHORIZED PICKUP INFORMATION

Student Name:

Grade:

Parent/Guardian(s):

Parent Phone:

Secondary Phone:

STUDENT DRIVER INFORMATION

Student does NOT drive to LHA Student IS permitted to drive to/from LHA

Vehicle Make:

Model:

Vehicle Type:

Color:

Year:

License Plate:

State:

I authorize the student named above to drive to and/or from LHA and understand that vehicle information should be kept current.

Besides the parent/guardian(s) listed above, will anyone else be permitted to pick up this student?

NO - only parent/guardian(s) listed above YES - the following person(s) are authorized

Authorized Person #1:

Relationship:

Phone:

Alternate Phone:

Authorized Person #2:

Relationship:

Phone:

Alternate Phone:

Additional authorized pickup person(s) / notes:

I confirm that the transportation and pickup information above is accurate and authorize LHA to rely on this information.

I will notify LHA administration if these permissions or vehicle details change.

Parent/Guardian Signature:

Date: