Holley Central School District
Holley, NY 14470
Transportation Department
Phone: 638-6316  Fax: 638-7279

REQUEST FOR PRIVATE OR PAROCHIAL TRANSPORTATION
(Please fill out completely)

Current Holley Resident ⁬				Today’s date: _____________________________

New Move In ⁬			Date moved/moving in ________________________________

Student’s Name _____________________	___________________	__________________
			Last				First				Middle

Parent/Guardian ____________________	___________________	__________________
Name			Last				First				Middle

Address: _______________________	___________________	__________________
		Street					City				Zip Code

Home Phone: _____________________	Work Phone: _______________________

Student’s Age: _________________		Birth Date: _________________________

Next Year Student Plans to Attend: __________________________________________
							Name of School

Grade Entering: __________________	School Year: ________________________

EMERGENCY PHONE NUMBER _____________________________

Section 3635(2) of NYSED law requires a request for transportation to a non-public school be made no later than April 1 of the preceding year. Requests made after this date will be reviewed for transportation eligibility.

SUBMIT BY APRIL 1 TO:	TRANSPORTATION SUPERVISOR
				HOLLEY CENTRAL SCHOOLS
				3800 NORTH MAIN STREET
				HOLLEY, NY 14470

ALTERNATE TRANSPORTATION REQUIREMENTS FOR BABYSITTER
Please remember that child care sites must be within the Holley School District boundaries.

PICK UP FROM ____________________	NAME/PHONE _________________________________

DROP OFF AT _____________________	NAME/PHONE__________________________________

OTHER INFORMATION REGARDING YOUR CHILDREN: ____________________________________

__________________________________________________________________________________