Duval County Magnet Service Request Form Survey

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1.

New/Pre-Registration

Address/Info Change

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2.

Parent/Guardian Information:

Parent/Guardian Information: Name
Street Address
City/Town
State
Zip/Postal Code
Home Phone
Cell Phone
Email Address

3.

Spouse/Guardian Information:

Spouse/Guardian Information: Name
Street Address
City/Town
State
Zip/Postal Code
Home Phone
Cell Phone
Email Address

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4. Student 1 Information:

Student 1 Information: Last Name
First Name
School
Date of Birth (MM/DD/YY)
Male or Female (M/F)

5. Student 2 Information:

Student 2 Information: Last Name
First Name
School
Date of Birth (MM/DD/YY)
Male or Female (M/F)

6. Student 3 Information:

Student 3 Information: Last Name
First Name
School
Date of Birth (MM/DD/YY)
Male or Female (M/F)

7. Emergency Contact Information (Other than Parent/Guardian)

Emergency Contact Information (Other than Parent/Guardian) Emergency Contact Name
Emergency Contact Home Phone:
Emergency Contact Mobile Phone:
Emergency Contact Work Phone:

8. SCHOOL BUS STOP SELECTION: (Tell us Route Number and Stop Location)

SCHOOL BUS STOP SELECTION: (Tell us Route Number and Stop Location)

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9. Form of Payment: (No cash or personal checks accepted)

Form of Payment: (No cash or personal checks accepted)

DISCLAIMER:

All information gathered on this registration form is considered confidential – For Official Use Only – and will not be shared with any other agency, group or individual.

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10.

ACKNOWLEDGEMENT

(You must answer "Yes" to have your submission considered)

I acknowledge that I am responsible for my family member’s conduct while they are using private student transportation. I understand that their misbehavior may result in disciplinary action that can result in suspension or revocation of transportation privileges. This responsibility extends to financial liability for any damage caused by my child. I understand that possession of a bus pass is mandatory. Payment is due two weeks prior to student transportation and there will be NO REFUNDS once transportation has started.

ACKNOWLEDGEMENT

(You must answer "Yes" to have your submission considered)

I acknowledge that I am responsible for my family member’s conduct while they are using private student transportation. I understand that their misbehavior may result in disciplinary action that can result in suspension or revocation of transportation privileges. This responsibility extends to financial liability for any damage caused by my child. I understand that possession of a bus pass is mandatory. Payment is due two weeks prior to student transportation and there will be NO REFUNDS once transportation has started.

Yes

No