Forms ACPS TransportationRequestESE

School Year

District

School

Grade

Student Last Name

Student First Name

Gender

Birth Date

Student ID

Select Weighted or Unweighted

Weighted (Requires special transportation)

Unweighted (Regular bus)

Section A: Student Information

Parent/Guardian

Last Name

First Name

Home Phone

Work Phone

Cell Phone

Address

Number

Street

City

Zip Code

Apartment

Mailing Address (if different from above)

Transportation required for:
Home Address
Drop Off Address

Section B: Stop Location Information

Date:

A.M Pick Up (from)

Home

Drop Off

P.M Drop Off (to)

Home

Drop Off

Section C: Alternate Address Information

Dropoff

Last Name

First Name

Home Phone

Work Phone

Cell Phone

Address

Number

Street

City

Zip Code

Apartment

Communication Issues Student uses sign language
Student uses a communication device (please describe):
Other (please describe):

Personnel

Attendant/paraprofessional to assist the student with An Attendant's name is required

Behavioral issues (include Behavioral Intervention Plan)

Physical Needs

Safety Needs

Nurse

1:1 Attendant
Other (please describe)

Other Needs

Isolated Reimbursement
Other (please describe)

Plan B (short-term plan when equipment is broken, nurse is sick, etc.)

Parent will transport the student
Other (please describe)

Submitted by

Last Name

First Name

Autism Spectrum Disorder	Intellectual Disability	Physical Therapy
Deaf or Hard-of-Hearing	Language Impairment	Specific Learning Disability
Developmental Delay (Age: 0-5)	Occupational Therapy	Speech Impairment
Dual-Sensory Impairment	Orthopedic Impairment	Traumatic Brain Injury
Emotional or Behavioral Disability	Other Health Impairment	Visual Impairment
Hospitalized or Homebound

Forms ACPS TransportationRequestESE

More than one student matches the criteria submitted. Please select the student to use

Parent/Guardian

Dropoff

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