Registration Form

This form is used as a pre-registration. After receipt, you will be contacted by our office to determine space availability and complete the registration process. Please note, we require a $35 non-refundable registration fee per family, per year. This will secure your child(ren)'s seat on the shuttle. Please contact us if you have any questions at (972) 987-0346. To terminate contract, our cancellation form must be completed and submitted in accordance with our Terms and Policy Agreement. Please note there is a $35 cancellation fee.

Registration Fee

$35.00

Rate Schedule

Auto Payments

Parents Infomation

Parent or Guardian 1

First Name

Last Name

Parent or Guardian 2

First Name

Last Name

Cell Phone 1

(###)

###

####

Cell Phone 2

(###)

###

####

Cell Phone Provider

This will allow for text notifications

Email Address

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Special Instructions

Child Information

Transportation Need

Child Name

First Name

Last Name

Birth Date

YYYY

Gender

Drop Off Address

If different from billing address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

School Name

Grade

Allergies

Medical and Other

Additional Children Names and information as requested above for 1st child

If more than one student is needing services

Insurance Information

IN CASE OF EMERGENCY

Insurance Provider

Subscriber’s Name

First Name

Last Name

Subscriber’s Birthdate

YYYY

Employer

Occupation

Work Phone

(###)

###

####

Group Number

Policy Number

Note Any Other Significant Medical Information:

In Case of an Emergency

We will contact the parents first, this information will be used if we are unable to reach the above parties

Authorized on Account

NOT LIVING AT SAME ADDRESS

First Name

Last Name

Relationship to Child

Contact Number

(###)

###

####

Other(s) Authorized on Account

Create An Account

User Name

door2doorshuttle.com/

Password

COVID-19 Release of Liability

Check to consent to release of COVID-19 liability

Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), our business is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfecting procedures in compliance with CDC guidance. Symptoms of COVID-19 include: o Fever o Fatigue o Dry Cough o Difficulty Breathing. You agree to the following: I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days. I affirm that I, as well as all household members, have not traveled outside of the country or to any city considered to be a "hot spot" for COVID-19 infections within the past 30 days. I understand that Door 2 Door Shuttle, LLC cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client. Our business is following these enhanced procedures to prevent the spread of COVID-19: We are in compliance with business wide practices for reducing the risk of COVID-19. By checking the box, I agree to each statement above and release Door 2 Door Shuttle, LLC from any and all liability for unintentional exposure or harm due to COVID-19.

Statement of Compliance

Check as a Statement of Compliance

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for my child (hereafter “Designated Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.

I agree to all Terms and Policies

By checking this field I agree that I have read the Terms and Policies.

All transportation agreements are based on a 10 month contract and require a 30 day notice of cancellation by client. In which case, any prorated amount becomes daily and weekly rate. The 30 day notice becomes in effect when the required cancellation form is completed and submitted. The link for our cancellation form can be found on the top of our Registration page and on our Tuition page. It can also be emailed upon request. Please note that there is a $35 cancellation fee.

Guardian Signature

Today's Date

YYYY

Start Date Requested

YYYY