Centerville Community School District	
Trip Request Form: Bus/Suburban/Car	
Employee: Fill out ALL information, then e-mail to your principal/supervisor.	
Principal: After approving, e-mail this form to Transportation (tim.kaster@centervillek12.org)	
Transportation Department will confirm with principal approval of vehicle	
Date Formats : mm-dd-yyyy	Time Formats: hh:mm am-pm Use TAB key to advance between fields	

Trip Date		School		Passenger
s		
	
Trip Destination		Depart from		Depart time		
	
Extra Equipment		Arrival Time		
	
Return time		Delivery time at school		
	
Name of person driving the Vehicle		
	
Meal Stop Required		If yes, where		
	
Purpose of trip	Field Day	
	
Transportation Requested by		Date		
	
Approved by		Date		

************************************************************************************************************

Transportation Department Use Only	
	
Vehicle # Assigned		Driver		
	
Route information		
	
Dispatcher signature		Date		
	
Destination Arrival
time		Destination Leave time		
	
Shuttle time		Time Set		Return Time		

Mileage out		Actual Number
Passengers–Students		
	
Mileage in		Adults		
	
Total miles traveled		
	
Remarks		

	
	
Driver’s Signature		Date