Series 707.8P - Special Education Transportation Request
Adopted: July 1983
Revised: February 2010
Student name (last, first, middle) |
Grade |
Date of birth |
Student ID# (required)
|
|||||||||||
Home address (number, street, apt., city, zip) |
Home phone
|
|||||||||||||
Parent/guardian name
|
||||||||||||||
Mother’s work phone
|
Father’s work phone
|
Mother’s cell phone
|
Father’s cell phone
|
|||||||||||
Daycare/alternative transportation address
Pick-up______________________________________________
Drop-off _____________________________________________
|
Days at alternative address ___M ___T ___W ___Th ___F
___M ___T ___W ___Th ___F |
Daycare/alternative phone
|
||||||||||||
Reason form submitted ____ new student ____ address change ____ program change ____ new school year ____ re-start ____ schedule change ____ daycare change ____ other (specify) ____________________
|
||||||||||||||
School name & phone # |
Program |
Program days ___M ___T ___W ___Th ___F
|
Teacher’s name |
Voice mail # |
||||||||||
Requested start date |
School start time |
School end time |
Recommended by IEP ___yes ___no Section 504 (attach copy) ___yes ___no Treatment ___yes ___no |
|||||||||||
Comments ____________________________________________________________________________________________ ______________________________________________________________________________________________________
|
||||||||||||||
Special Education Disability ____ Deaf/hard of hearing ____ Blind/visually impaired ____ Physically/health impaired ____ DCD: severe/profound ____ DCD: mild/moderate ____ EBD ____ Autism spectrum disorders ____ ECSE ____ Specific learning disability ____ Traumatic brain injury ____ Speech/language ____ Other (specify)______________ Special condition ____ Individual Health Plan (attach copy) ____ Nurse riding with student |
Medical ____ ADD/ADHD ____ Cerebral palsy ____ Diabetic ____ Hemophiliac ____ Nonverbal ____ Spina bifida ____ Respiratory, type______________________________ ____ Seizure, type______________________________ ____ Temporary injury, type______________________________ ____ Other________________
|
Assistive equipment ____ Electric wheelchair ____ Manual wheelchair ____ Braces ___Walker/crutches ____Oxygen/respirator ____ Torso restraint ____ Carseat (built in) ____ Height ____ Weight ____ Carseat (regular) ____ Height ____ Weight
|
Method of Transfer Home School _____ _____ Hand-to-hand transfer Parent or other adult must meet the bus at the curb and either carry or walk the student to the house as needed. ALL ECSE STUDENTS MUST BE MET AT THE DOOR OF THE BUS.
_____ _____ Eye-to-eye transfer Driver or chaperone will have eye to eye contact with parent or other adult before releasing student. Not applicable to ECSE students.
_____ _____ Independent transfer Student is allowed to enter the house alone. Not applicable to ECSE students. |
|||||||||||
If the student has specific transportation needs due to medical, behavior, etc., the Special Education Transportation Plan on back page must be completed.
Emergency informationEmergency contact (other than parent)____________________________________________________________________ Home phone _____________________ Work phone ____________________ Relationship to student________________ Name of neighbor student can be left with__________________________________________________________________ Neighbor’s address________________________________________________________ Phone ______________________ Physician & clinic_________________________________ Phone _________________ Hospital (preference)____________
|
Transportation use onlyDate received_________________________________ Requested start date ______________ Pick-up bus___________________ Time__________ Drop bus___________________________ Time________ Stop ID_______________________________________ Stop ID__________________________________________ Run ID_______________________________________ Run ID__________________________________________
|
Special Education Transportation Plan
Explain medical conditions/disability including behaviors, toileting needs, sensory issues, etc. that would impact the student during transit: __________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Considerations for the Bus Intervention Plan:
- An alternative plan should be in place if the student is physically aggressive when it is time to board the bus.
- Plan should include options for the driver/aide if the student becomes a danger to self or others while in transit, if appropriate.
- Adaptation page of IEP must be attached to this page.
BUS INTERVENTION PLAN: Detail intervention strategies used in school setting or recommended for the bus to address the needs identified above (i.e. student prefers shoes off, sitting in the front/back seats, not seated by certain students, allowed to have certain items on the bus such as headsets, book, toy, etc.).
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Date |
Driver/Aide Notes |
Staff Initials |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Procedure/707.8P/2-24-10