bus application form 2014 DiMino Bus Service, Inc. 1040 Rockaway Avenue Brooklyn, NY 11236 (718) 257-2422 Please print all information clearly. Child’s name: ______________________________________________________________________________ Child’s age:* ________________ Home address: ____________________________________________________________________________________ DOB ________________ Cross streets: ___________________________________________________________________________________________________________ Home phone: ___________________________________________________________________________________________________________ Parent’s name and cell phone: _______________________________________________________________________________________________ Parent’s name and cell phone: _______________________________________________________________________________________________ Additional emergency contact: _____________________________________________________________________________________________ Primary e-mail (please print clearly): ______________________________________________________________________________________ SERVICE REQUIRED Bus Service for Specialty Camps
r r r r
Week of June 16:
Camp:
Stop:
Week of June 23:
Camp:
Stop:
Week of August 11:
Camp:
Stop:
Week of August 18:
Camp:
Stop:
Total weekly camps
@ $225/250 per week =
Summer Experience and Performing Arts Camps
r Summer Experience or Performing Arts Camp: r Door-to-door service r Designated stop service
@ $775/$825 = @ $675 =
Stop: Please enclose a check or money order payable to DiMino Bus Service, Inc.
Total $
Please mail to: DiMino Bus Service, Inc., 1040 Rockaway Avenue, Brooklyn, NY 11236 I,
parent/guardian of
, will
r meet my child every afternoon at the bus stop/at my home. r authorize to pick my child up at the bus stop/my home. r give the driver/matron permission to let my child off at the bus stop/house alone. I accept full responsibility for this action. Signed:
Date:
Relationship to camper: Route and pick-up times are not available until the Wednesday before camp starts. You will receive an e-mail or phone call from a member of the DiMino Staff with full details of your child’s transportation. Therefore, it is important to include contact phone numbers and a primary e-mail address where you can be reached.
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