Formulaires
(current)
Connexion
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Change or Addition to Special Ed Transportation
INSTRUCTIONS :
District scolaire
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Dufferin-Peel Catholic DSB
Other Schools
Upper Grand District School Board
Wellington Catholic District School Board
École
Niveau
Nom de l'élève
Prénom de l'élève
Sexe
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F
M
N
S
X
Date de naissance
N° de l'élève
Identificateur alternatif
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:
Same as home address (see above)
If address is different, please complete the section below:
House/Apt. number
Street name
Suffix
City/Town
Postal/Zip code
Contact name
Contact phone
Contact phone (alternate)
Afternoon Drop-off Address:
Same as home address (see above)
If address is different, please complete the section below:
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
Door-to-door
Booster Seat
Support Animal
Support Person
Harness*
Chest Measurement
Weight:
Effective Date
Retire Date
* The use of a Restraint System (harness) is justifiable only in medical cases requiring additional physical support for the posture of a student. The harness cannot be used for behaviour management.
Section III – Reason(s) for Special Transportation Request (check all that apply)
Please check the appropriate item(s)
Wheelchair
Crutches
Blindness
Out of Area
Medical
:
Provincial (article 19)
Section 20
Diagnostic
Other
:
Section IV – Transportation
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
Understands English
Comments
Understands French
Comments
Needs additional communication tool(s)
Specify:
Medication
List carried by student
Carried by student (e.g. backpack)
To be communicated to emergency services
Allergies
Section VI – Comments
Soumis par
Je reconnais avoir pris connaissance des procédures de transport qui s’y appliquent.
Nom de famille
Prénom
Courriel
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