Bus Pass Application

Student Information

Request Number*

School of Attendance*

Student ID

Grade*

Student First Name*

Student Last Name*

Date of Birth*

Home Address*

City*

Parent Information

Parent or Guardian First Name*

Parent or Guardian Last Name*

Email Address*

Home Phone Number

Cell Phone Number*

Work Phone Number*

Emergency Contact Section

Emergency Contact (1)*

Phone Number (1)*

Emergency Contact (2)

Phone Number (2)

Emergency Contact (3)

Phone Number (3)

Bus Information

Important Information

Click Here for School Bus & Bus Stop Safety Information

As the parent/guardian, I will accept full responsibility and will not hold the driver or Norwalk-La Mirada Unified School District responsible for anything that may happen after delivering my child to the return point. I have read the School Bus & Bus Stop Safety Information handout relating to transportation privileges and hereby agree to abide by them.

Information Agreement*

Submitted By

Date*

Attachments

Please upload a current wallet size photo of the student