APPLICANT DETAILS

RESIDENTIAL ADDRESS

Street Address

Town/Suburb

State

Postcode

Exact distance from home to school (km)

Exact distance from home to bus stop (km)

POSTAL ADDRESS

APPLICANT DETAILS

RESIDENTIAL ADDRESS

Street Address

Town/Suburb

State

Postcode

Exact distance from home to school (km)

Exact distance from home to bus stop (km)

POSTAL ADDRESS

Same as residential address?

Same as residential address

Postal Address

Town/Suburb

State

Postcode

PARENT/GUARDIAN DETAILS

Parent/Guardian 1 First Name

Parent/Guardian 1 Surname

Parent/Guardian 1 Telephone

Parent/Guardian 2 First Name

Parent/Guardian 2 Surname

Parent/Guardian 2 Telephone

Email Address

EMERGENCY CONTACTS

Emergency Contact 1 Name

Emergency Contact 1 Relationship

Emergency Contact 1 Telephone

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Telephone

TRAVELLER DETAILS

STUDENT ONE

First Name

Surname

Date of Birth

Travel Start Date

School Enrolled

Year Level at Time of Travel

Medical problems or requirements

Travel Days

MondayTuesdayWednesdayThursdayFriday

STUDENT TWO

First Name

Surname

Date of Birth

Travel Start Date

School Enrolled

Year Level at Time of Travel

Medical problems or requirements

Travel Days

MondayTuesdayWednesdayThursdayFriday

STUDENT THREE

First Name

Surname

Date of Birth

Travel Start Date

School Enrolled

Year Level at Time of Travel

Medical problems or requirements

Travel Days

MondayTuesdayWednesdayThursdayFriday

PARENT/GUARDIAN TO COMPLETE

I certify that:

• All the above details are true and correct.

• I will notify the principal in writing within 7 days of any change of address or school.

• I agree to pay the costs of repairs or damage to the bus, or its replacement if totally destroyed, caused by the vandalism or deliberate act of my child/children.

• I consent to release this information to Public Transport Victoria (PTV) to assist with planning for transport services.

• I will notify the principal in writing should my child/children no longer require transport assistance.

I accept the authority of the coordinating principal with regard to student discipline on the school bus service.

I agree to abide by the above Conditions of Travel.

I understand that if I or my child/children do not comply with the Conditions of Travel, it may result in my child/children not being permitted to travel on the school bus service.

Parent/Guardian Acceptance

I confirm that I have read and agree to the above declaration and Conditions of Travel.

Parent/Guardian Name

Date

STUDENT(S) TO COMPLETE

I accept the authority of the coordinating principal with regard to student discipline on the school bus service.

I agree to abide by the above Conditions of Travel.

Student One

Student Name

Student One Acceptance

Student One agrees to the Conditions of Travel.

Date

Student Two

Student Name

Student Two Acceptance

Student Two agrees to the Conditions of Travel.

Date

Student Three

Student Name

Student Three Acceptance

Student Three agrees to the Conditions of Travel.

Date