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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 information

Emergency 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 only

Date 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.).

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Date

Driver/Aide Notes

Staff Initials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Procedure/707.8P/2-24-10