Request for Home to School Travel Assistance (July 2016)

This form is for parents and carers requesting assistance with home to school travel. Before you complete this form, please read the Travel Assistance Policy.

Please return your completed form to:

Special Educational Needs Service, Green Zone, 2nd Floor, Kensington Town Hall, Hornton Street, London. W8 7NX.

Section 1 – You & your child’s details
Your Child
Name: / DOB:
Name(s) of Parents / Carers / Mobile Phone Number / Home Phone Number
Mother/ Carer 1:
Father/ Carer 2:
Home Address of Child
Post Code:
Emergency contact
Name of Emergency Contact
Contact Phone Number
Relationship to child
The Nursery / School / College (ie Setting)
Name of setting you are requesting travel assistance to:
Address of setting you are requesting travel assistance to:
Post Code:
Telephone Number:
Contact Name:
When will travel assistance be needed? (Please circle where appropriate)
Daily / mornings only / afternoons only / beginning & end of term
Date travel assistance requested from:
Date travel assistance to end (if known):
School Start Time:
School Finish Time:
The needs of your child (Please circle the appropriate answer)

Wheelchair user

/

Yes / No

/

Physically able

/

Yes / No

Baby seat /

Yes / No

/ Booster seat /

Yes / No

Medical needs

/ Yes / No (if yes please give details in the space below)

Can your child travel without an escort?

/ Yes / No (if no please give details in the space below)
Section 2 – Why are you applying for travel assistance?

Please tell us why you are applying for travel assistance. Please read the Travel Assistance policy and consider your answer(s) carefully. It may help to consider the following:

·  Reason(s) preventing you from taking your child to school. If there is a medical reason, please obtain a medical report from your GP stating why it would injure your health to transport your child to school (some GPs may charge you for this).

·  Reason(s) why your child cannot travel independently

·  Any other reason why travel should be authorised as specified in the Travel Assistance Policy

If you run out of space please continue on the back of this sheet

Supporting Evidence

Are you enclosing any additional documents e.g. supporting letters from a doctor?
Yes No
If yes, please give details below and refer to reports from your child’s statutory assessment.
I confirm that the information provided is accurate to the best of my knowledge.
Name:
Signed: / Date:
The personal information contained within this form is provided in order to arrange travel assistance for your child. We have a duty to protect the information you have provided to us on this form under the Data Protection Act 1998 to ensure it is kept confidentially. The information will be stored securely, both on paper and electronically, and will only be shared for purposes relating to travel assistance, including sharing with a third party organisation for service provision. It will not be shared further with anyone else without your knowledge, unless we are required to do so by law.

Please note that transport will not be provided for:

·  Hospital, medical, or dental appointments

·  Day trips, outside of the school’s remit

·  Children taken ill during the school day

·  Schools where parent/carers are making their own arrangements

·  Schools which are not the nearest available school

·  To and from work experience (unless exceptional circumstances e.g. physical or medical needs)

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SEN Special Travel Assistance Application Form