8/08
JEFFERSON COUNTY SCHOOL DISTRICT 509J
Madras, Oregon
Request for Special Transportation
Reason for Request:
□ Child on IEP □ Temporary Medical/Physical □ Temporary Home Displacement □ 504 □ Court
□ ECSE (IFSP) □ EI □ BIC □ OSB/OSD □ Other: ______
*ALLOW 3 DAYS FOR PLACEMENT ON ROUTE*
ATTACH PHOTO
Student’s Name: ______
Date of Birth: ______(mm/dd/yy)
Home Address: ______
City, State, Zip: ______
Parent/Guardian: ______
Home Phone: ______Emergency Phone: ______
Work Phone: ______Work Phone: ______
Childcare Provider (Person or Agency Name): ______
Childcare Address: ______
Childcare Phone: ______Days to Attend: ______
Disability/Diagnosis/Behavioral Issues: ______(List All)
Medication(s): ______Side Effects: ______(List All)
1. Mode of transportation: □ Wheel chair □ Walks independently □ Car seat □ Harness
2. Student positioning and assistance requirements (list any or n/a): ______
3. Special diet and/or food restrictions (list any or n/a): ______
4. Include any other pertinent medical considerations (i.e., seizures, diabetes, etc).
See attached protocols.
5. Can the child be released at home to someone other than parent guardian? □ Yes □ No
If yes, list ALL names and addresses of authorized people:
______
______
Director of Special Programs Date Parent/Guardian (If available) Date
______
School Bus Driver Date Teacher/Case Manager Date
SPECIAL PROGRAMS TRANSPORTATION PROTOCOL
When securing Special Programs transportation for your students, please do the following:
1. Send the following paperwork to Sherri Fessler, JCESD
a. Completed transportation request form
b. The Prior Notice of Special Education Action, citing the program change
c. Copy of the IEP cover sheet that shows that transportation has been written down under related services with appropriate start/stop dates
2. Please remember to complete the ENTIRE transportation request form. Do not leave any questions blank. This form gives the transportation department the needed and necessary information to assure a student’s safety (medically and behaviorally) on the bus.
3. Sherri will review the request form and Barbara Garland will sign the permission for Special Programs transportation.
4. When writing down Special Programs transportation on the IEP under related services, simply write “Special Programs Transportation”. Do not write “door-to-door service” or other descriptors.
5. Do not send completed transportation requests directly to Bill McChesney at the Transportation Department. Sherri will be sending those directly to them after approval from Barbara.
6. If you know of a Special Programs student that has moved and no longer requires special transportation, please let Sherri Fessler know, either by e-mail or a quick phone call.
THANKS!