Transportation Request

Transportation Request

UPDATED Complete the following form for any student that requires transportation to or from school. Please allow 3-5 schools days to process the request.

What is request for the student?*

New Student

Placement Change

Address Change

Time Change

Schedule Change

Delete Transportation

Place Student On Hold

Shuttle

Summer

SUN/EDO

Fall

Submitter's First and Last Name*

Submitter's Email Address*

Student Needs RFID Badge

Are you the Coordinator?

Select or enter value

After - School Coordinators Name

After - School Coordinators Office Phone/Extension

After - School Coordinators Cell

AM/PM

AM Only

PM Only

Both

Program Days of Attendence:

Monday

Tuesday

Wednesday

Thursday

Friday

Request Departure Time from The School:

Are there multiple students on this request?

If Yes, please attach an Excel spreadsheet with student ID numbers.

Select or enter value

How many students are on the attached excel list of ID numbers?

Students Information

Does this student require specialized transportation?*

(e.g. transportation on IEP/504, McKinney-Vento, DHS, etc.)

Yes

No

Student ID Number*

First Name*

Last Name*

Grade

Select or enter value

Is this a Title 9A/McKinney-Vento student?

School Information

What school does the student attend?*

Select

Start Date*

End Date

Do they need to be meet?

Home

School

No

Needs to be watched

Pickup/Drop-off Authorized Adult

Does the student have a modified schedule?

Yes

No

Days Attending/Times

(e.g. M - F 9:30-12:00)

Dates program will not be in session:

What billing information do you have?

Billing Information

Budget Account Code

Address/Phone/Email/Budget Account Code

Parent/Guarding Information

Parent/Guardian Information

Mom

Dad

Guardian

Foster

Parent/Guardian Name

Street Address

City, State, Zip

Home Phone Number

Cell Phone Number

Mom Work Phone

Dad Work Phone

Is there an alternate address to which the student will be routed?

Select or enter value

Name of Alternate Address Adult

Address

City, State, Zip Alternate Address

Phone Number

Emergency Contact Name #1

Emergency Phone #1

Emergency Contact Name #2

Emergency Phone #2

Case Manager

Case Manager Ext.

Primary Eligibility

Secondary Eligibilities 1

Secondary Eligibilities 2

Secondary Eligibilities 3

Secondary Eligibilities 4

Does this student require Special Equipment?

Yes

No

Assistant

Allergies

Asthma

Attention Deficit

Diabetic

Non-Ambulatory

Non-Verbal

Seizures

Does this student have any Mobility or Assistive Devices?

Yes

No

Standard Wheelchair

Motorized Wheelchair

Walker

Crutches

Braces

Respiratory Equipment

Assistance On/Off Bus

Carseat/Booster

Special Equipment Notes

Notes*

File Upload

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