Acton-Boxborough​ ​Elementary​ ​Bus​ ​Pass

This​ ​form​ ​must​ ​be​ ​delivered​ ​to​ ​the​ ​school​ ​office​ ​before​ ​2:00​ ​pm​​ ​the​ ​day​ ​before​ ​the​ ​change​ ​is​ ​effective​,​ ​OR​ ​bus​ ​ ​pass​ ​will​ ​not​ ​be​ ​accepted​. Bus​ ​changes​ ​cannot​ ​be​ ​taken​ ​over​ ​the​ ​phone;​ ​except​ ​in​ ​an​ ​emergency​ ​to​ ​be​ ​determined​ ​by​ ​the​ ​school​ ​principal.

Student​ ​Name​ ​:___________________________________​ ​ ​ ​ ​ ​ ​Date​ ​Submitted:______________________ Teacher:______________________________​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​School:_____________________________ ​ ​ ​ ​ ​ ​ ​ ​ ​Parent​ ​Requesting​ ​bus​ ​pass:​ ​_______________________________​ ​ ​ ​ ​ ​ ​ ​_________________________ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​(​ ​PRINT​ ​name)​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​(Phone​ ​number)

​ ​Parent​ ​Signature:​ ​________________________​ ​Parent​ ​phone​ ​#​ ​(if​ ​questions​ ​arise):_________________ ⬜​ ​Permanent​ ​change​ ​for​ ​every:​ ​(day(s)​ ​of​ ​the​ ​week)______________Start​ ​Date:​ ​___/___/___​ ​End​ ​Date​ ​___/___/___ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​OR ​ ​ ​ ​ ​ ​ ​ ​ ​⬜​ ​One​ ​day​ ​change​ ​for:​ ​DAY:___________________​ ​DATE:______/______/______ My​ ​student​ ​has​ ​permission​ ​to​ ​ride​ ​BUS​ ​#​ ​______​ ​to​ ​__________________________________________________. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​(PRINT​:​ ​EXISTING​ ​BUS​ ​STOP​ ​ ​) My​ ​student​ ​will​ ​be​ ​in​ ​care​ ​of:​ ​___________________________________________________________,​ ​who​ ​can​ ​be ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​(PRINT​ ​name​ ​of​ ​adult)

​ ​reached​ ​by​ ​phone​ ​at​ ​number:__________________________________

HARD​ ​COPY​ ​MUST​ ​BE​ ​PRESENTED​ ​TO​ ​THE​ ​BUS​ ​DRIVER​ ​TO​ ​ENSURE​ ​SAFE​ ​ARRIVALS Must​ ​be​ ​signed​ ​by​ ​a​ ​school​ ​official:_______________________________________________  

Acton-Boxborough​ ​Elementary​ ​Bus​ ​Pass

This​ ​form​ ​must​ ​be​ ​delivered​ ​to​ ​the​ ​school​ ​office​ ​before​ ​2:00​ ​pm​​ ​the​ ​day​ ​before​ ​the​ ​change​ ​is​ ​effective,​ ​OR​ ​bus​ ​ ​pass​ ​will​ ​not​ ​be​ ​accepted. Bus​ ​changes​ ​cannot​ ​be​ ​taken​ ​over​ ​the​ ​phone;​ ​except​ ​in​ ​an​ ​emergency​ ​to​ ​be​ ​determined​ ​by​ ​the​ ​school​ ​principal.

Student​ ​Name​ ​:___________________________________​ ​ ​ ​ ​ ​ ​Date​ ​Submitted:______________________ Teacher:______________________________​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​School:_____________________________ ​ ​ ​ ​ ​ ​ ​ ​ ​Parent​ ​Requesting​ ​bus​ ​pass:​ ​_______________________________​ ​ ​ ​ ​ ​ ​ ​_________________________ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​(​ ​PRINT​ ​name)​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​(Phone​ ​number)

​ ​Parent​ ​Signature:​ ​________________________​ ​Parent​ ​phone​ ​#​ ​(if​ ​questions​ ​arise):_________________ ⬜​ ​Permanent​ ​change​ ​for​ ​every:​ ​(day(s)​ ​of​ ​the​ ​week)__________________​ ​Start​ ​Date:​ ​___/___/___​ ​End​ ​Date​ ​___/___/___ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​OR ​ ​ ​ ​⬜​ ​One​ ​day​ ​change​ ​for:​ ​DAY:___________________________​ ​DATE:______/______/______ My​ ​student​ ​has​ ​permission​ ​to​ ​ride​ ​BUS​ ​#​ ​______​ ​to​ ​__________________________________________________. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​(PRINT​:​ ​EXISTING​ ​BUS​ ​STOP​ ​ ​) My​ ​student​ ​will​ ​be​ ​in​ ​care​ ​of:​ ​___________________________________________________________,​ ​who​ ​can​ ​be ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​(PRINT​ ​name​ ​of​ ​adult)

​ ​reached​ ​by​ ​phone​ ​at​ ​number:__________________________________

HARD​ ​COPY​ ​MUST​ ​BE​ ​PRESENTED​ ​TO​ ​THE​ ​BUS​ ​DRIVER​ ​TO​ ​ENSURE​ ​SAFE​ ​ARRIVALS Must​ ​be​ ​signed​ ​by​ ​a​ ​school​ ​official:_______________________________________________  

AB Dismissal Form.pdf

Page 1 of 1. Acton-Boxborough​ ​Elementary​ ​Bus​ ​Pass. This form must be delivered to the school office before​ ​2:00​ ​pm​ ​the​ ​day​ ​before​ ​the​ ​change​ ​is​ ​effective​, OR bus pass will not​ ​be​ ​accepted​. Bus changes cannot be taken over the phone; except in an emergency to be ...
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