Confidential Emergency Transportation Information Form

If your child requires special needs transportation services, please work with your case manager to determine if transportation services can be placed in your child's Individual Education Plan (IEP) or contact the special education department.

For students with special needs, including allergies or other health conditions, please fill out this confidential information form in case of an emergency during transportation.

One student per form please

Personal and Contact Information

Is this a new form or a change to an existing Emergency Transportation form?required

This is a new form

This is a change to an existing form

Date

Must contain a date in M/D/YYYY format

School:

Program:

What School Year is this for?

Student Namerequired

First Name

Middle (optional)

Last Name

Graderequired

Date Of Birth:

MM/DD/YYYY

When Student Will RiderequiredChoose all that apply

Choose all that apply

Home Addressrequired

Apt. #

Cityrequired

Staterequired

Ziprequired

Home Phone Numberrequired

XXX-XXX-XXXX

Parent/Guardian 1 Namerequired

First Name

Last Name

Parent/Guardian 1 Daytime Contact Numberrequired

XXX-XXX-XXXX

Parent/Guardian 1 Cell Number

XXX-XXX-XXXX

Parent/Guardian 1 Email Addressrequired

Parent/Guardian 2 Namerequired

First Name

Last Name

Parent/Guardian 2 Daytime Contact Numberrequired

XXX-XXX-XXXX

Parent/Guardian 2 Cell Number

XXX-XXX-XXXX

Parent/Guardian 2 Email Addressrequired

Will your child be PICKED UP at home or an alternate/daycare address?

Home

Alternate or Daycare

Alternate/Daycare Street Address

City

State

Zip

Alternate/Daycare Contact name:

Alternate/Daycare Phone Number:

XXX-XXX-XXXX

Will your child be Dropped OFF at home or an alternate/daycare address?

Home

Alternate or Daycare

Alternate/Daycare Street Address

City

State

Zip

Alternate/Daycare Contact name:

Alternate/Daycare Phone Number:

XXX-XXX-XXXX

IEP & Specialized Transportation Information

Please check all boxes that apply.

Time of drop off at school

Time of pick up at school

Location of pick up and drop off at school

School Contact:

Staff Phone Number:

XXX-XXX-XXXX

Is the wheelchair manual or electric?

Manual

Electric

Signs of Emergency

Steps to Take in Emergency

Other Safety/Health Factors Not Listed:0 / 1500

Doctor’s Name:

Hospital/Clinic:

Phone Number:

Prescription medications the child is taking:

Alternate Address/Person where child can bereleased if parent/guardian is not home:

Comments/Concerns/Questions?

My signature below gives permission to share this information with transportation staff & authorizes care be provided to my child as directed in this plan or to call 911 for emergency care. I understand every effort will be made to contact me or the emergency contacts listed.required

First Name

Last Name

Date

Must contain a date in M/D/YYYY format