Car Rider Application Form

Leib Elementary Car Rider Times: A.M. 8:40- 8:55 ; P.M. 3:10- 3:50 (Students Dismissed at 3:35)

Parent Name(s):

Student(s) Name(s):

Vehicle Make & Model:

Names of Additional Adults Who Can Transport My Child

By signing below, I agree to follow the elementary school's traffic pattern for car riders. I understand my permit may be revoked by the building principal for violating school traffic patterns, rules, and policies. If my permit is revoked, I understand that I must park in the visitor section and sign in at the school office to pick up my child. I understand that I will be issued a permit to place on my rear view mirror at the time of car rider pick up so it can be visible to the staff members on duty. Once issued a permit, I understand I will be charged a replacement fee of $4.00 if the permit is lost or stolen.

Name of the Parent/Guardian Completing the Form

Date of Form Completion: MM/DD/YYYY

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