Application for Before and After School Shuttle Service



PLEASE FILL OUT THE INFORMATION BELOW AND FAX IT TO US AT (540) 373-7766 FOR INFORMATION, CALL TRANSPORTATION AT (540) 419-7766SCHOOL ATTENDING_____________________________________________________STUDENT NAME__________________________________ GRADE__________________SCHOOL ADDRESS (PICKUP LOCATION) ____________________________________________SCHOOL PICKUP TIME _____________________________________________________ HOME ADDRESS (DESTINATION) ________________________________________________PLEASE CHECK DAYS YOU NEED TRANSPORTATION: MON.TUES.WED.THUR.FRI.AM [ ]PM[ ] AM [ ]PM[ ] AM [ ]PM[ ] AM [ ]PM[ ] AM [ ]PM[ ] parent (FATHER)/guardian full name_______________________________________parent (FATHER)/ guardian signature ______________________________________parent (MOTHER)/ guardian full name ______________________________________parent (MOTHER)/ guardian signature ______________________________________home phone ________________________work phone_________________________other numbers where we may reach you__________________________________THIS FORM MUST BE RECEIVED BEFORE TRANSPORTATION BEGINSPLEASE INFORM THE SCHOOL THAT PRIDE TRANSPORTATION, LLC WILL BEGIN PICKING UP YOUR CHILD STARTING ON THE FOLLOWING DATE (______________________). (Please fill in requested date) Payment upon completion of service is by(place and X next to the payment option)*note 3.95% processing for Credit Cardcash______ American Express______ discover ______ visa ______ MasterCard______Credit card number: ______________________________________________________________________expiration date:Cvv CODE: ____________________________________________________________________BILLING ADDRESSname: _______________________________________________________________________street address: _______________________________________________________________________city: _______________________________________________________________________state:zip: _________________________________________________________PAYMENT AGREEMENTfor THE FOLLOWING ADDRESS: ____________________________________________. (please insert your address)I _________________________________________, understand and agree that I (please insert your name)Am financially responsible for payment of all services received in the amount of $__________ per week/per student. I agree to pay that total in full on Friday of each week.PARENT/GUARDIAN SIGNATURE: ____________________________________________dATE: ______________________________________________Mile Radius (0.0 - 3.0 miles)One-Way ? ?$55.00 per week/per studentRound-Trip $80.00 per week/per studentMile Radius (3.1 - 6.0 miles)One-Way ? ?$65.00 per week/per studentRound-Trip $90.00 per week/per studentMile Radius (6.1 - 9.0 miles)One-Way ? ?$75.00 per week/per studentRound-Trip $100.00 per week/per studentMile Radius (9.1 -?12.0 miles)One-Way ? ?$85.00 per week/per studentRound-Trip $110.00 per week/per studentMile Radius (12.1 -?15.0 miles)One-Way ? ?$95.00 per week/per studentRound-Trip $120.00 per week/per studentMile Radius (15.1 -?18.0 miles)One-Way ? ?$105.00 per week/per studentRound-Trip $130.00 per week/per student ................
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