CHILD/STUDENT RIDERSHIP FORM 2016

CHILD/STUDENT RIDERSHIP FORM
2016-2017
PLEASE CHECK HERE FOR:
STUDENT OR
SUMMER FUN
(Separate forms must be filled out)
Southern Iowa Trolley
215 E Montgomery St.
Creston, Iowa 50801
CHILD Last Name: ____________________
DATE OF BIRTH: ____________________
Ph: (641) 782-6571
Toll Free: (866) 782-6571
Fax: (641) 782-4096
First Name: _________________
AGE: _________________
PARENT/LEGAL GUARDIAN INFORMATION:
Last Name: ________________________ First Name: _________________________
*Cell Phone: _____________ *Home Phone: _____________ *Work Phone: ______________
Home Address: _____________________________ City: _______________________
PROVIDER INFORMATION:
If picking up from child care provider please enter Name and Phone Number of the provider:
Last Name: _______________ First Name: _______________ *Phone: _______________
*PLEASE NOTIFY S.I.T. IMMEDIATELY OF ANY PHONE NUMBER CHANGES!
SCHEDULE:
Pick up From: ___________________________ Circle pick up days: M T W TH F
Destination: ____________________________________________________
Time program starts / Start time: ________________ AM / PM
Return From: ____________________________ Circle return days: M T W TH F
Destination: ____________________________________________________
Time program ends / End time: ________________ AM / PM
******************************************************************************
If schedule is different than above:
Pick up From: ___________________________ Circle pick up days: M T W TH F
Destination: ____________________________________________________
Time program starts / Start time: ________________ AM / PM
Return From: ____________________________ Circle return days: M T W TH F
Destination: ____________________________________________________
Time program ends / End time: ________________ AM / PM
*********************************************************************************************
EMERGENCY MEDICAL AUTHORIZATION:
Every effort will be made to notify parents immediately in case of emergency. Parents/Legal Guardian will be
notified first by Southern Iowa Trolley and/or the hospital. In the event that Southern Iowa Trolley and/or the
hospital is unable to reach the parent/legal guardian, I ___________________________ (parent/legal guardian) of
_____________________________ (child) do hereby give my permission and/or consent to the personnel of
Southern Iowa Trolley to secure and authorize such emergency medical care and/or treatment as my child (named
above) might require while being transported by Southern Iowa Trolley.
SIGNED: ____________________________________________ DATE: _________________
(PARENT OR LEGAL GUARDIAN)
*********************************************************************************************
OTHER PEOPLE AUTHORIZED FOR CONTACT OR TO MAKE CHANGES IN CHILD’S SCHEDULE:
1. ___________________________________________________________________________________________
(NAME AND RELATIONSHIP)
(PHONE)
2. ___________________________________________________________________________________________
(NAME AND RELATIONSHIP)
(PHONE)
*********************************************************************************************
7/22/2016
Serving Adams, Adair, Clarke, Decatur, Ringgold, Taylor & Union Counties P a g e | 1
PARENTAL WAIVER (NOT AVAILABLE FOR CHILDREN UNDER 9 YEARS OF AGE)
I GIVE MY PERMISSION FOR ___________________________ TO BE DROPPED OFF AT HOME EVEN
THOUGH AN ADULT OR OLDER SIBLING MAY NOT BE PRESENT AT THAT LOCATION WITH
THE FOLLOWING EXCEPTIONS (IF NONE PLEASE STATE SO):
______________________________________________________________________________
SIGNED: ____________________________________________ DATE: _________________
(PARENT OR LEGAL GUARDIAN)
I HAVE READ AND UNDERSTAND THE POLICIES AND PROCEDURES ON RIDERSHIP AS SET
FORTH BY SOUTHERN IOWA TROLLEY.
NO ONE IS ALLOWED TO RIDE UNLESS THEY PRESENT A TICKET, PASS OR MONEY TO THE
DRIVER WHEN BOARDING THE BUS. IF YOU KNOW YOUR CHILD WILL NOT BE RIDING YOU
MUST NOTIFY SOUTHERN IOWA TROLLEY AT (641)-782-6571 OR TOLL FREE (866)-782-6571 TO
AVOID BEING CHARGED FOR THE RIDE.
*********************************************************************************************
Unless this paragraph is crossed out, Southern Iowa Trolley has my permission to photograph my child for use in
promoting the Southern Iowa Trolley.
*********************************************************************************************
SIGNED: ____________________________________________ DATE: _________________
(PARENT OR LEGAL GUARDIAN)
IMPORTANT NOTICE TO PARENTS / GUARDIANS AND CHILDREN
Because of the danger to young passengers and the risk to this agency, the Southern Iowa Trolley
will have very low tolerance for passengers riding without seatbelts fastened. Seatbelts are more
than a behavioral issue and will not follow the “Disruptive Behavior” policy. We cannot afford
to transport your child if he or she does not keep the seatbelt fastened.
Our policy of seatbelts being fastened will be strictly enforced. Failure of a passenger to have his
or her seat belt fastened will result in immediate suspension of service until a parent/guardian
and the child have met with agency staff to discuss the situation. Parents/guardians should
discuss this policy with their children.
I have read and understand the statement printed above and agree to abide by it.
__________________________________
____________________________________
Parent/Guardian Signature and Date
Passenger Signature and Date
PARENT/GUARDIAN – RETURN PAGES 1&2 TO SOUTHERN IOWA TROLLEY! THANK YOU!!!
7/22/2016
Serving Adams, Adair, Clarke, Decatur, Ringgold, Taylor & Union Counties P a g e | 2
TRANSPORTATION POLICIES AND PROCEDURES
In a concerted effort with parents to provide safe, reliable and affordable transportation, the Southern Iowa Trolley
has established the following policies and procedures:
DISRUPTIVE BEHAVIOR
If a child becomes disruptive, refuses to stay seated or keep seat belt on, uses profanity, is involved
in fighting, or any other problem that may interfere with the driver’s ability to drive, the following
policy’s will be enforced:
1st offense - The driver will fill out incident report and the child will receive a verbal
warning. Parents will be notified by the Dispatcher or Transit Director on the 1st occurrence.
2nd offense – The driver will fill out incident report, the child will receive a written warning.
Parents will be called by the Dispatcher or Transit Director on the 2nd occurrence.
3rd offense - The driver will fill out incident report. Parents will be notified by the Transit
Director. Childs actions may result in termination of service for the remainder of the semester or
indefinitely. If the third offense occurs during December, suspension of service will continue
through the month of January and maybe longer depending on severity of offense.
PAYMENT
One of the following payment options may be used. Cash, check, money order or Credit cards (with markup) are
accepted at Southern Iowa Trolley. If your child owes for 5 rides or the monthly pass has not been purchased
by the 5th of the month and arrangements to pay have not been made through dispatch, the driver will not
pick up or drop your child off. Failure to pay will result in termination of service.
1. PAY-AS-GO: Fare may be given directly to driver at the time of boarding. Money may also be brought
into or mailed to the dispatch office at 215 E Montgomery, Creston, IA 50801.
2. TICKET: Payment is due upon receipt of ticket. The 12 ride student ticket may be purchased anytime.
3. MONTHLY K-12 PASS: Passes are to be purchased by the 5th of each month. AFTER the 5th of the
month there will be a $10 late fee applied to the cost of the pass.
PASSES are available for one way or two way transportation. If your child has a one way pass and the
need for transportation a second time is required on that day, they will need to pay regular student fare for
the 2nd ride.
4. LOST OR MISPLACED TICKETS: S.I.T. will not be responsible for lost or misplaced tickets.
Credit will NOT be given for lost or misplaced tickets. Monthly passes are good from the 1st of the month to the
end of the month only.
RIDER INFORMATION
A ridership form MUST be filled out for EACH child every SUMMER and FALL. Address and phone numbers
must be kept up to date. Please notify S.I.T. of any changes as soon as possible.
CHANGE NOTIFICATION
Parents/legal guardians must notify S.I.T. of changes in scheduled pick up or drop off addresses. If S.I.T. has not
been notified of the change and the driver goes to the scheduled place of pick up or drop off, an additional fare will
be charged if no notice was given to change pick up or drop address. Please notify S.I.T. as soon as possible of any
changes. If change is permanent, a NEW RIDERSHIP FORM MUST BE FILLED OUT!
FOOD/DRINK
In an effort to keep the Trolley clean, food and/or drinks are not allowed. If the child is taking treats to school for
the day please make sure they are in an enclosed container in their backpacks or given to the driver to keep until the
child reaches their destination.
TOYS
For the safety of the children all toys should be placed in backpacks or given to the driver until the child’s final
destination.
7/22/2016
Serving Adams, Adair, Clarke, Decatur, Ringgold, Taylor & Union Counties P a g e | 3
LOST CLOTHING/ITEMS
Drivers walk through the vehicle at the end of each route. If your child is missing an item please contact Southern
Iowa Trolley as soon as possible. Any items left over at Christmas break and the end of the school year is given to
charity. A lost and found box is located at the S.I.T. office.
CHILDREN UNDER 3 YEARS
Children less than three years of age MUST be accompanied by an adult and must be in a car seat or other approved
safety securement provided by the family or contracting organization.
SAFETY SECUREMENTS
All passengers must stay seated and wear seat belts/safety restraint (unless medical release has been given in writing
by a physician) at all times while on board the vehicle. Passengers, who refuse to fasten seatbelts or unfasten seatbelt
while the Trolley is moving, will be written up. SEE DISRUPTIVE BEHAVIOR.
PASSENGER TIMELINESS
Children should be dressed and ready to go when the Trolley arrives. S.I.T. will not wait any longer than two (2)
minutes at one location for your child to come out of the door. If your child misses the Trolley, S.I.T. will return
to pick up your child, after the other passengers have been delivered to their destination in order to prevent everyone
from being late. S.I.T. reserves the right to charge an additional fare for return pickups.
S.I.T. TIMELINESS
Pickup and delivery time may vary fifteen (15) – thirty (30) minutes due to riders being added or removed,
road conditions, trains across tracks, or unforeseen problems such as replacement driver or vehicle problems.
RELEASE OF CHILD
Unless a parent/legal guardian has signed the parental release section, an adult/authorized person must be visible
to the driver when children are delivered or the child will not be allowed to disembark the vehicle. If an
adult/authorized person is not found, the child will remain on the vehicle until the end of the route. S.I.T. dispatch
will make every attempt to contact the parent/legal guardian or an emergency contact. Additional charges may be
applied at the discretion of the Transit Director to drop child off at alternate destination or scheduled destination.
I HAVE READ AND UNDERSTAND THE POLICIES AND PROCEDURES ON RIDERSHIP AS SET
FORTH BY SOUTHERN IOWA TROLLEY.
NO ONE IS ALLOWED TO RIDE UNLESS THEY PRESENT A TICKET, PASS OR MONEY TO THE
DRIVER WHEN BOARDING THE BUS. IF YOU KNOW YOUR CHILD WILL NOT BE RIDING YOU
MUST NOTIFY SOUTHERN IOWA TROLLEY AT (641)-782-6571 OR TOLL FREE (866)-782-6571 TO
AVOID BEING CHARGED FOR THE RIDE.
SIGNED: ____________________________________________ DATE: _________________
(PARENT OR LEGAL GUARDIAN)
7/22/2016
Serving Adams, Adair, Clarke, Decatur, Ringgold, Taylor & Union Counties P a g e | 4
SOUTHERN IOWA TROLLEY
PUBLIC TRANSIT RATES
Effective July 1st, 2015
IN TOWN RATES
General Public (19-59 yrs.): $3.25 per ride or 12 punch ticket $36.00 ($3.00 per ride)
2 yrs & below Free – MUST BE ACCOMPANIED BY AN ADULT
Preschool / K-12 / College Students (3yrs & above):
ONE WAY – $32.00 per month ($1.52 per ride) 2nd child $20.00
TWO WAY - $57.75 per month ($1.38 per ride) 2nd child $45.00
STUDENT TICKET - $1.75 per ride or 12 punch ticket $21.00
SUMMER FUN BUS - $.50 per ride or $40.00 unlimited rides
Senior (60+ years) Suggested Contribution:
$1.75 per ride
6 punch ticket for $9.00 ($1.50 per ride)
Or 12 punch ticket $15.00 ($1.25 per ride)
* “FIFTY CENT FRIDAY” - $.50 Senior Day will now be every Friday! *
FOR OUT OF TOWN RATES CALL:
(641) 782-6571
OR
Toll Free at 1-(866) 782-6571
NOTIFICATION OF RIGHTS UNDER TITLE VI
The Southern Iowa Trolley operates its programs and services without regard to race, color, and national origin in accordance with
Title VI of the Civil Rights Act. Any person who believes she or he has been aggrieved by any unlawful discriminatory practice under Title VI
may file a complaint with the Southern Iowa Trolley.
For more information on the Southern Iowa Trolley civil rights program, and the procedures to file a complaint, contact 866-7826571, (Relay Iowa 711); Email: [email protected]; or visit our administrative office 215 E. Montgomery St., Creston, IA 50801.
For more information, visit http://www.southerniowatrolley.org/.
7/22/2016
Serving Adams, Adair, Clarke, Decatur, Ringgold, Taylor & Union Counties P a g e | 5