Youth Information Sheet Child Information Child's Name* DOB* Gender*MaleFemale Ethnicity Parent Information Parents/Guardian 1)* Parents/Guardian 2) Child’s Home Address* Contact Phone 1)* Contact Phone 2) Parent 1 Work Phone Parent 2 Work Phone Email Address* Day Care Information Day Care Name* Provider's Name* If origin or destination is a daycare, a PARENT/DAY CARE PROVIDER SIGNOFF will need to be completed prior to beginning service. Daycare Phone Daycare Address Days*MondayTuesdayWednesdayThursdayFriday Origin (name & address) Destination (name & address)* One-way tripRound-trip Start Time* End Time* Emergency Contacts Emergency contact information: Please list name, phone number and relationship to child:* Please list any special needs or information that would help us safely transport your child: List of people the child can be left with if you or your daycare provider are not available: Contact Name 1* Contact Phone* Contact Name 2 Contact Phone Please read and sign FARES: Call 605-624-7433 to purchase over the phone. Options: $2.50 for a pre-scheduled ride; $5 for a same day ride; $90 for a Jr. VIP Pass (4 yrs. or under); $50 for a punch card or $75 for a VIP Pass. Drivers will hand out the passes the first day of service. I, the parent or guardian, agree to allow Vermillion Public Transit provide transportation for my child. I will notify Vermillion Public Transit as soon as possible of any scheduling changes or cancellations. I have reviewed the VPT Passenger Handbook. Signature* What is 8+2?
