School Bus Pass Application Form Student Details Firstname: Surname: School: Route: School Year: Please Select.. Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year 11 Year 12 Year 13 Bus Stop: Please Select.. Derby - Chellaston Rd Bus Stop Outside Premier (Zone A) Derby - Derby Rd Bus Stop Opposite West Ave South (Zone A) Derby - Swarkstone Rd Bus Stop just before Riber Drive (Zone A) Shardlow - London Road - Before Wakelyn Close (Zone B) Loughborough - Loughborough Schools Foundation Shardlow - London Road - Lay-by op Clock warehouse Mobile Phone: Authorise sending of SMS to Student Tick if disabled access to school transport is required Address Address 1: Address 2: Village: County: Postcode: Parent/Guardian Details Full Name: Relationship: Please Select.. Parent Guardian Phone 1: Phone 2: Email: Payment Scheme: Please Select.. Payment in full (ZONE A) (1 x £1300.00 Total £1300.00) 3 Payments (ZONE A) (3 x £440.00 Total £1320.00) 8 Payments (ZONE A) (8 x £168.00 Total £1344.00) Payment in full (ZONE B) (1 x £900.00 Total £900.00) 3 Payments (ZONE B) (3 x £307.00 Total £921.00) 8 Payments (ZONE B) (8 x £118.00 Total £944.00) Authorise sending of SMS to Parent Photograph of Student Upload a photograph to appear on the pass -head and shoulders - Must be taken in portrait mode. Format required JPG, BMP or PNG. You will need to complete one application form per student * Please ensue the photograph is a high resolution portrait Notes (Add any additional comments here): Part Time Options I Agree to Roberts Travel Group Terms & Conditions (You must agree to these terms in order to proceed) View T&Cs Proceed to payment Part time options × Please select your part time travel options, You will only be allowed to create a travel pass for the current or next term period Select Term Please School Term.. Start Date End Date Day of Week AM Travel PM Travel Monday UNKNOWN DAT101 No Travel UNKNOWN DAT101 No Travel Tuesday UNKNOWN DAT101 No Travel UNKNOWN DAT101 No Travel Wednesday UNKNOWN DAT101 No Travel UNKNOWN DAT101 No Travel Thursday UNKNOWN DAT101 No Travel UNKNOWN DAT101 No Travel Friday UNKNOWN DAT101 No Travel UNKNOWN DAT101 No Travel Alternative Route: Please Select..