This form is to be completed during the student’s team meeting and the Building Administrator (from student’s enrollment building) is to arrange transportation

SPECIAL TRANSPORTATION

Date:____________________
Student’s Name:________________________________________________________________
Parent’s Name:_________________________________________________________________
Home Address:_________________________________________________________________
Home Phone:__________________________ Work Phone:____________________________

This form is to be completed during the student’s team meeting and the Building Administrator (from student’s enrollment building) is to arrange transportation. Primary provider should place copy in student’s file.

SPECIAL TRANSPORTATION

Date:____________________

Student’s Name:________________________________________________________________

Enrollment Building:_____________________________________________________________

Parent’s Name:_________________________________________________________________

Home Address:_________________________________________________________________

Home Phone:__________________________ Work Phone:____________________________

Emergency Contact Person:______________________________ Phone:___________________

What is the nature of this student’s needs that requires special transportation?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2.	Please complete the following information:
A.	Pick Up Location:_______________________________________________________
B.	Attending School:______________________________________________________
C.	School/Program Arrival Time:_____________________________________________
D.	School/Program Departure Time:__________________________________________
E.	Drop Off Location:______________________________________________________
F.	Regular Bus or Special Bus (circle one)

If special bus, please list what accommodations are necessary (e.g., lift, wheelchair lock-down capability, climate control, etc).:

_____________________________________________________________________

G.	Does this student have any health considerations? Yes / No
H.	Please list any other special accommodations/considerations for this student while on the bus (e.g., para, car seat, harness, etc.).:

_____________________________________________________________________

Principal/ Admin. Designee Signature:______________________________________________