Alamance-Burlington School System –Transportation Request Form for Exceptional Children
CONFIDENTIAL CONFIDENTIAL
PLEASE PRINT
Student: Parent/Guardian:
Address: City: ZIP:
Age: DOB: Grade: Race/Sex : Home Phone:
School: Teacher Contact:
Work Phone/Contact Person: 1. 2.
Emergency Contact Person/ Phone #
*Requested Pickup / Drop off Address: If location is a daycare or an apartment complex, enter name, address and phone number.
AM Address: PM Address:
*Addresses which are outside the attendance zone of the school of attendance or the school of assignment may not be served pursuant to the ABSS Transportation Department Statement of Guidelines for Transportation of Exceptional Children and the Center Pick-up/Drop-off Procedures Statement dated August 18, 2003.
Explanation of Special Transportation Considerations or Health Concerns: (Ex: Feeding Tube, Oxygen, Seizures, Allergies etc.)
Parent Permission: Check One: ☐Yes ☐ No
For safe transportation purposes: Can child be secured in a Child Safety Restraint
System (CSRS) appropriate for age/weight/height as determined by the Transportation Department? ☐ Yes ☐ No
Permission to exit the bus at specified stop without an adult present. My student has permission to exit the bus at the allocated stop without an adult present. I understand that by signing this form, I am giving permission for my student to get off the bus and return home without adult supervision. I release Alamance-Burlington School System of responsibility once my child has left the bus.
For students nine years or younger or students in a Centrally Located Program (CLP), adults must be at the bus stop and in view of the bus driver for any student receiving special transportation.
Signature Date
I understand that it is my responsibility to notify Exceptional Children’s Department of any address change. The Transportation Department requires a minimum of seven (7) work days to make original assignment of or any necessary address changes for transportation. If the student does not ride the bus for three (3) consecutive school days, it is the responsibility of the parent/guardian to contact the appropriate transportation supervisor to resume transportation services.
I have received a copy of the 2017-2018 ABSS Transportation Department Statement of Guidelines for Transportation of Exceptional Children.
______
Parent/Guardian Signature Date
EXCEPTIONAL CHILDREN’S STAFF USE ONLY (EC TEACHERS)
Assignment Date Effective: (7 school days from submission to Transportation)
School Teacher Contact
Address Phone:
Classification: Section 504? (Y/N) Arrival Time: Departure Time:
(Complete if arrival/departure time is different from the published bell schedule.)
Additional Information/Special Instructions:
Supplemental Form is attached: ☐ Yes ☐ No
Mark Appropriate Needs: Child Safety Restraint System (CSRS): Child’s weight/height
☐Wheelchair ☐ Safety Asst. ☐ Oxygen. ☐ Nurse ☐ Other
For emergency school bus evacuation purposes, student ☐should or ☐ should not be removed from CSRS or wheelchair.
Exceptional Children’s Department Contact Phone # Date Faxed to Transportation