School Climate & Student Support

Families In Transition (262) 619-4620

Racine Unified School District

3109 Mount Pleasant Street, Racine, WI 53404

Dates: ______

Week one attendance:

Student # / School / Monday / Tuesday / Wednesday / Thursday / Friday

Week two attendance:

Student # / School / Monday / Tuesday / Wednesday / Thursday / Friday

Distance one way (per Google maps): ______X______

(# trips/day) = ______

Miles driven round trip/day

Current cost of gas per gallon: $______

Average miles per gallon: ______

Make and Model:______

Miles driven round trip each day ______/ Average miles per gallon______=

(# Gallons used per day) ______

Current cost of gas per gallon______X # of gallons used per day ______=

(cost per day): $______

cost per day: $______X days in attendance______=

Total amount on card for two weeks: ______

*Gas reimbursement depends on days attended