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OSTA AccessibleTransportation
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
Birth Date
Student ID
Alternate ID
More than one student matches the criteria submitted. Please select the student to use
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Student Information
Attending School
Home School
Attending School Phone #
Attending School Principal
Language Spoken/Understood
Emergency Contact Information
Parent/Guardian
Address
Home Phone
Cell Phone
Parent/Guardian
Address
Home Phone
Cell Phone
Language Spoken/Understood
Alternate Emergency Contact
Name
Address
Home Phone
Cell Phone
Language Spoken/Understood
Request Information
Date of Request
School Year
School Board
School Principal making Request
Requested Start Date
Requested End Date
Reason for Request
Please select a reason.
Please specify the name of the class/program and location.
Mobility/ Regular Program
Special Education Class/ Program and location
(Please Name)
Medical/ Regular Program
Please provide brief rationale for using accessible transportation.
If the student is not in a system class, is there a plan developed to support the students ability to access regular tranportation?
Other Information
If the student is attending a half day class, please indicate the school and Principal of this site.
School
Principal
School Phone Number
Medical Information
Students Doctor
Phone Number
Does the student have any life threatening allergies?
Yes
No
If yes, please list
Does the student have an Auto Injector?
Yes
No
If yes, please indicate where it will be carried
Does the student have a bleeding disorder?
Yes
No
Does the student have seizures?
Yes
No
If yes, please describe the symptoms
Additional Information: (For example, does the student have an individual protocol for transportation?)
Please check any that apply
Visually Impaired
Physical Disability
Developmental Delays
Non-Verbal
Hearing Impaired
Sign Language
Other/Additional Information (e.g., self-regulation)
Mobile: alone unassisted
Mobile with assistance
Mobile using assistive device
Mobile using wheelchair
Special Equipment required for Safe Transit
NOTE: Refer to OSTA Policy T21 – V2 re: Equipment
Booster Seat
Car Seat
Wheelchair
Seat belt cover
Harness
Other
*The parent should complete the OSTA form for the use of special equipment.
List other conditions or concerns of which we should be aware in order to best serve the student in transit
The following are strategies recommended to support the safe transit of the student
In the event of an Emergency Evacuation, the following responses may be taken by the driver
*Remove students to a safe, secure location
*Call 911
*Contact transportation provider who will contact parents/guardians
Please check only APPLICABLE boxes; enter FULL Residential or School Address and enter the time of taxi/small vehicle arrival requested AT/FROM THE SCHOOL.
The third and fourth line would only be appropriate for those student in a Board-supported half day class.
Special Education Class/Program and Location
(Please Name)
Pick up from
Address of Residence OR School
Time
Deliver to
Address of Residence OR School
Time
Pick up from
Address of Residence OR School
Time
Deliver to
Address of Residence OR School
Time
Submitted by
Parent Signature
Principal Signature
Superintendent Signature
I acknowledge that transportation procedures will apply.
Last Name
First Name
Email
ALL INFORMATION IS CONFIDENTIAL. KEEP IN A CLOSED PRIVATE SPACE WHEN NOT IN USE
The personal information provided on this form and any other correspondence relating to transportation is collected under the authority of the Education Act, the Accessibility for Ontarians with Disabilities Act, and in accordance with the Municipal Freedom of Information and Protection of Privacy Act. The information will be used to arrange transportation as per Ottawa Student Transportation Authority policies and procedures, and to give information to employees and transportation providers to carry out their job duties. In addition, the information may be used to deal with matters of health and safety and is required to be disclosed in the event of an emergency.
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