Special Educational Needs/Medical needs
Travel Assistance Application Form

Please note all sections must be completed including all information regarding the child’s needs. Eligibility for travel assistance will be based on the information on this form.

Any request must be accompanied by supporting evidence from a relevant medical professional or Educational Psychologist.

Child’s full name: / Date of birth:
Child’s address:
Parent/Carer’s name:
Parent/Carer’s telephone no:
Parent/carers Email address:
School attending:
School address:
Transport required with effect from:Date:
Transport required until:Date:
Days transport required between home and school:
Mondayam pm (Arrival time at school - / School departure time - )
Tuesdayampm (Arrival time at school - / School departure time - )
Wednesdayam pm (Arrival time at school - / School departure time - )
Thursdayampm (Arrival time at school - / School departure time - )
Friday am pm (Arrival time at school - / School departure time - )
1. Your child’s Special Educational Needs (please tick all the boxes that apply)
Social, emotional and mental health / Physical or neurological impairment
Learning difficulties / Visual impairment
Speech and language difficulties / Hearing impairment
Other (please specify)
2.Please indicate which of these criteria apply to your child (please tick all the boxes thatapply)
My child is unable to walk
My child is unable to walk short distances (up to 400 meters) unaided
My child is unable to travel/walk safely to school on their own
My child needs to travel/walk with a supervising adult
My child is unable to use public transport unaccompanied
My child is unable to use public transport when accompanied
My child is unable to handle money to pay for bus fares
My child needs to travel in wheelchair
3. If you have ticked any of the above please give details to support the statement(s). If required continue on separate sheet and attach.
Please note this application cannot be processed without supporting evidence from a relevant medical professional or Educational Psychologist.
4. Specialist Healthcare Support

If your child has a specialist healthcare need, this will be considered to ascertain whether a risk assessment and/or additional support are required on your child’s journey to school. This will ensure that your child’s individual healthcare needs are suitably supported and appropriately managed.

Please confirm if your child has any of the following by ticking the appropriate box:

Epilepsy
Emergency medication for epilepsy (e.g. Buccal Midazolam)
Anaphylaxis (severe allergic reaction requiring adrenaline auto injector)
Diabetes
Use of oxygen
Oral or nasal suction required (excess salivation, risk of choking etc)
Any other medical intervention (please give details)

If you have ticked any of the above, please enclose a copy of your child’s HealthCare Plan, dated within the last year and signed by a healthcare professional. We cannot deal with your application without this document.

5. Transport equipment requirements (please tick to specify)
Infant seat / Travels in a wheelchair
Booster seat / Travels in an electrical wheelchair
Crelling harness / Takes a folding wheelchair in vehicle
Takes a folding buggy in vehicle / Takes a K-Walker or walking frame in vehicle
Child’s height / Child’s Weight
Wheelchair / Unloaded weight (kgs)
Manufacturer / Model
Length (cms) / Width (cms) / Height (cms)
6. Our aim is to provide suitable travel arrangements that meet eligible children’s needs. To enable us to do so please provide us with any useful information which may assist us. For example behaviour linked to needs such as spitting, hitting, aggression, undressing.
7. Please advise us of anything that may help your child’s journey be more comfortable i.e. taking a favourite toy or listening to music.
8. Fuel reimbursement

Nottinghamshire County Council (NCC) may offer parents/carers a reimbursement for them to take their child to school where the cost of reimbursement is the most efficient way of providing travel assistance for eligible children.

The mileage rate is paid at 22.6p to cover fuel costs for return journeys at the start and end of the standard school day. Please indicate below if you would like to be considered for fuel re-imbursement.

I wish to be considered for fuel reimbursement

Declaration

I confirm that:

  • To the best of my knowledge, the information I have given is true and correct
  • I will inform you immediately of any change of address or if my benefits change or cease and understand that transport will need to be reassessed, which may result in no further entitlement.
  • I understand thatNCC may make enquiries from other central and/or local government bodies about the validity of the information provided on this form
  • I give permission for NCCto request and receive information relating to my child from all health professionals in his/her care with regards to transport needs. I also consent to this information being shared with all relevant professionals who are involved with the transportation of my child
  • I accept that NCC is committed to maintaining acceptable standards of behaviour on all school transport. Behaviour on vehicles is monitored by NCC and bad behaviour can result in transport being re-evaluated and, in severe cases, withdrawn
  • I understand that if my child is unwell then it will be my responsibility to collect him/her from school
  • I understand that travel assistance will only be provided from the main residential address which is the address on this application form
  • I understand that Home to School Transport will not be provided to before or after-school activities, e.g. breakfast clubs, homework clubs, enrichment activities
  • I understand that the County Council, in accordance with European contract regulations and the Council’s financial regulations, will re-tender contracts periodically to achieve best value. This may result in changes to the contractor, route and timings. The Council will endeavour to limit the impact of these changes as much as possible.
  • I confirm that someone has completed this application on my behalf and agree that the content is correct*.

*delete if inappropriate

Parent/carer signature / Date
For Nottinghamshire County Council use only
Yes / No
Pick up point
Shared vehicle
Individual escort
Shared escort
Health Care Plan (please attach)
Type of transport required
Any other information
Authorised by: Signed: Date:
Cost code (s):

1

Please return this form to the Transport Policy and Engagement Assistant, Transport and Travel Services, Floor 6 – TBH,Nottinghamshire County Council, County Hall, West Bridgford, Nottingham, NG2 7QP or email to