Wagner Middle School 167 Replacement Request MetroCard Form (RRMC) *Student’s Full Name:

*Student’s Class Number :

*Date:

*Parent/Guardian’s Signature:

(*required) Note: _______________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Please Note: Students may pick up their MetroCards at dismissal daily, in room 124. Metrocard replacement, may take up to 7 days. When possible, the parent coordinator will try and replace your child’s MetroCard within 48 hours.

Office Use Only: Date & Time Received: _________________________ Signed by parent?: Yes No First time card was replaced? Yes No

If no, what number is this? _______________

Deactivate Card number:_______________________ completed:______________________ New Card Number: ___________________________ Half Available replacement card?: Yes No

FFSE

If no, ordered new card on _____________

Child received new card on: ___________________ Entered into ATS: _______________

Full