Transport Application Form

Student Transport Application Form (for Students aged 16-21)

The LEA will not normally provide assistance with travel or transport for a student aged 21 or over.

We require up to ten workingdays once your application is agreed in order to decide the most appropriate method of transport assistance and to make suitable arrangements. However, if your child has specialist medical needs, it may take up to 3 months.

This form should be completed in conjunction with the London Borough of Merton Transport Policy for Students over the age of 16.

ACONTACT DETAILS

Students’ Full Name:

Male / Female(delete as appropriate)

Student’sDate of Birth:

Full Name (Parent or Carer):

Main Contact Number(s): (Parent or Carer)

Are you applying as a Looked After Child (with Social Care) Yes/No

If yes, what is the name of the social worker?:

Will you be a candidate for independent travel training, now or in the future?

Yes / No

Your Address (where you wish receive correspondence about this application):

Your Postcode:

Your Email Address:

Name of school attended:
Did you have a statement of special educational needs while at school:
Have you previously received transport from Merton:
Name of college for which you require transport to:
Name and length of course you are attending:
Is the course full or part time:
Is this course offered at a nearercollege:
Date which you require transport to commence:
Are you able to walk to and from the vehicle on your own Yes  No 
If NO, give reason

BELIGIBILITY QUESTIONS

What is the reason for your application? (Please fill in one of the options below 1 - 5)

1.The school/college named on my statement is beyond statutory walking distance

(statutory walking distance is 2 miles if aged 7or under, and 3 miles ifaged 8 orover)

If yes, please go straight to section C

Yes/No

2.My disability means that I cannot walk any distance to school/college even if I were accompaniedby an adult

(Note: we are not asking about the availability of an adult, just about your child’s abilities)

We may need to contact a professional who is involved with your child. Please provide details of a Head Teacher, Hospital Consultant or other professional who knows your child.
Child’s disability:
Name of professional:
Job title of professional:
Contact number:

If yes and you have entered the details above, please go to straight to section C

Yes/No

3.I need accompanying to school/college but no-one can accompany me because other adults in our household are disabled

We will need to contact a professional who is involved with you to verify this information. Please provide details of your Hospital Consultant, if you have been treated/diagnosed at hospital, or, if not, your GP.
Adult’s disability:
Name of professional:
Job title:
Contact number:
If yes, and you have entered the required details, please go straight to section C /

Yes/No

4.I am from a low income family

Does your child receive free school meals? OR
Do you receive maximum Working Tax Credit?
If applicable, please enclose recent evidence of your working tax credit, and go to section C /

Yes/No

Yes / No

5.There is another reason for my application

Please explain in detail why you need travel assistance and what sort of travel assistance you are requesting. If temporary, for how long will you need it?
We will require documentary evidence to support your application. Please enclose copies of any relevant documents you think will demonstrate your child’s need for travel assistance. /

Yes/No

Have you applied for all available passes, grants, Government schemes, and bursaries from the school, college or other training establishment?

We will require documentary evidence of your requests to support your application /

Yes / No

Do you qualify for income-based job seeker’s Allowance or income support, or your parents qualify for these benefits (or the equivalent under the Universal Credit system)

Yes / No

CTYPE OF TRAVEL ASSISTANCE REQUESTED

Do you need MertonCouncil to transport youin a taxi or minibus?

Yes / No

LB Merton has recently started a new programme called ‘Personal Travel Assistance Budget’ where the SEN Transport Dept. will give funding directly to a parent/carer to arrange travel assistance.

Please answer to show your interest in this programme. /

Yes / No

DVEHICLE TRANSPORT (only fill in this section if you are requesting a taxi or minibus)

Main contact name:

Relationship to child(e.g. parent, carer, guardian, social worker):

Email address:

Main contact telephone number:

Alternative telephone number (e.g. mobile/work):

Emergency contact name:

Relationship to child(e.g. father, sister, aunt, neighbour):

Emergency telephone number:

Home address for pick-up and drop-off(if different from your address in A above):

Postcode:

School or Establishment Name to which the student needs to be transported:

Address:

Postcode:

If your child is less than 1.35 metres (4’ 4”), please tell us their exact height?

Under new statutory seatbelt/ restraint legislation Merton Transport Services will no longer be able to transport you if they do not have details of your height

Do you use a wheelchair?

If Yes, please complete the Wheelchair UserInformation Form attached

Yes / No

Start date / from when you need transport assistance?(dd/mm/yyyy):

Do you need an escort / passenger assistant? Please bear in mind that all Merton Minibuses have an escort and a driver on board. All vehicles have child locks on the doors. Special seat belts are available which are difficult for children tounfasten. School staff will meet your child from the door of the vehicle and escort them into school if this is necessary.

If yes, please tell us your reasons:

We may require evidence showing that your child will be unsafe without an escort. In order to save time, please enclose any relevant documents and contact numbers with your application

Yes / No

Can you travel in a vehicle with other people?(e.g. a shared taxi or minibus)

If No, please tell us your reasons:

We may require evidence that your child is unsafe to travel with other children. In order to save time, please enclose any relevant documents or contact numbers with your application form

Yes / No

Are youvisually impaired?

If yes, please describe how this impacts your child’s transport:

Yes / No

Please describe any medical needs youhave (e.g. epilepsy, oxygen, allergies):

Please describe any communication needs youhave (e.g. non-verbal, signing):

Please describe any emotional or behavioural needs youhave (e.g.resists change, aversion to physical contact):

Can you manage vehicle steps? Yes / No

Can you sit upright to travel? Yes / No

Do you need to use any special equipmentwhen travelling?

Please describe any otherphysical needs you have:

Please tell us the days and times that you needtransport

daily / weekly / fortnightly / half termly / termly / other?

If other, please provide exact details:

Please enter times clearly in the boxes below. If you do not need transport on specific days or at certain times, please leave the cells blank.

Days attending

Mon

Tue

Wed

Thu

Fri

Sat

Sun

School start time

School finish time

Please only request transport for thedays and times that you really need it. Asking for part of a week or only certain mornings/afternoons will not prejudice your application. If your needs change during the year, contactTransport Serviceson 020 8545 4794 or email

EADDITIONAL INFORMATION

Please use this space to explain why you think you need assistance with travel arrangements to and from school/college

FSIGNATURE

I declare that the information above is correct.
I will inform the Council immediately if any details change.
I agree to the information above being shared with any agencies who may be involved in transporting or assisting my child as a result of this application.
NAME:
SIGNATURE: …………………………………………………DATE……………………………
Please print your name in the signature box if you are replying via email.

Please return this form to:

SEN Team, SEN & Disabilities Integrated Service

London Borough of Merton

8th Floor, Merton Civic Centre

London Road, Morden

Surrey. SM4 5DX

020 8545 4812

Or email to (if emailing, please just print your name in the signature box)

WHEELCHAIR USER INFORMATION FORM

Please complete the following information about your child’s wheelchair

1. / Make:
2. / Model:
3. / Weight kgs
……………………….
4. / Can you transfer to a vehicle seat? / Yes / No
5. / Does it fold for storage? / Yes / No
6. / Does it fasten with Karabiner guides? / Yes / No
7. / Is it crash tested? / Yes / No
8. / Is it transportable? / Yes / No
9. / Does it have any special characteristics or medical devices
(e.g. high back, tray, foot restraints, head rest, kneeblocks)
Please explain whether these can be removed for transport or not: / Yes / No
10. / Does someone need to carry your belongings in and out of the vehicle? / Yes / No
11. / Is there any other information which transport services need to know in order to arrange a secure and comfortable journey for you?
12. / If you have one, please provide the name and phone number of an expert we can call who knows about your wheelchair specification and usage?

Your name in capitals:

Your signature:Date: