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.

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__________________________________________

Date

Driver/Aide Notes

Staff Initials