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DSB1 SpecialTransportationRequest_EN
District
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Dufferin-Peel Catholic DSB
Other Schools
Upper Grand District School Board
Wellington Catholic District School Board
School
Grade
Student Last Name
Student First Name
Gender
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F
M
N
S
X
Birth Date
Student ID
Alternate ID
More than one student matches the criteria submitted. Please select the student to use
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Section I – Student Information
Student timetable (Special transportation request)
Regular
5 days/week
Monday
Morning
Afternoon
Morning and Afternoon
Tuesday
Morning
Afternoon
Morning and Afternoon
Wednesday
Morning
Afternoon
Morning and Afternoon
Thursday
Morning
Afternoon
Morning and Afternoon
Friday
Morning
Afternoon
Morning and Afternoon
Comments
Home Address
Street number
Street name
Suffix
City/Town
Postal/Zip code
Telephone (home)
Telephone (mother / guardian)
Telephone (father / guardian)
Morning Pickup Address
Adresse de la résidence (voir section ci-dessus)
Si l’adresse est différente, complétez la section ci-dessous:
House/Apt. number
Street name
Suffix
City/Town
Postal/Zip code
Contact name
Contact phone
Contact phone (alternate)
Afternoon Drop-off Address
Adresse de la résidence (voir section ci-dessus)
Si l’adresse est différente, complétez la section ci-dessous:
House/Apt. number
Street name
Suffix
City/Town
Postal/Zip code
Contact name
Contact phone
Contact phone (alternate)
Section II – Services Required (check all that apply)
Taxi / Minivan
Meet at Door
Booster Seat
Support Animal
School Bus Monitor
Car Seat
Harness
*
Chest Measurement:
Weight:
Effective Date
Retire Date
* L'utilisation d'un ensemble de retenue (harnais) est justifiable que dans les cas médicaux nécessitant un support physique pour le maintien de la posture de l'élève. Le harnais ne peut pas être utilisé pour gérer les comportements de l'élève.
Section III – Reason(s) for Special Transportation Request (check all that apply)
Please check the appropriate item(s)
Wheelchair
Crutches
Blindness
Stroller
Medical
:
Provincial (article 19)
Section 20
Diagnostic
Other
:
Section IV – Transport
Aboard the vehicle
How to interact/communicate with the student
Possible behavioural issues (e.g. escape, aggression)
Prevent ative strategies (e.g. music, object to keep them busy)
School responsibilities
At Pickup
Accompany the student to the vehicle. After boarding, attach the student's seatbelt / wheelchair seatbelt / harness.
At Drop-off
Meet the student at their vehicle at the specified time. Detach the student's seatbelt / wheelchair seatbelt / harness.
Parent / guardian responsibilities
At Pickup
Attach the student's seatbelt / wheelchair seatbelt / harness.
At Drop-off
Meet the student at their vehicle at the specified time. Detach the student's seatbelt / wheelchair seatbelt / harness.
Comments
Section V – Communication (check all that apply)
Can travel with other students
Comments
Understands English
Understands French
Needs additional communication tool(s)
Comments
Specify
Medication
List carried by student
Location (e.g. backpack)
To be communicated to emergency services
Allergies
Section VI – Commentaires
Submitted by
I acknowledge that transportation procedures will apply.
Last Name
First Name
Email
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