Request that auto fills subsequent requests for siblings and boundary checks

District

School

Grade

Student Last Name

Student First Name

Gender

Birth Date

Student ID

Alternate ID

Section A: Student Information

Parent/Guardian

Last Name

First Name

Home Phone

Work Phone

Cell Phone

911 Address

Number

Street

City

Postal Code

Apartment:

Mailing Address (if different from above)

Transportation may be provided to and/or from home/sitter/joint custody location, if the arrangement is permanent (5 days per week) and this location can be safely scheduled into the regular routes and is within the pupil's home school attendance boundary.

Transportation required for:

Home Address

Sitter Address

Joint Custody Address

Joint Custody Sitter Address

Is transportation for sibling required?

Is guardian required at stop?

Is there a medical condition?

Section C: Alternate Address Information

Sitter

Last Name

First Name

Home Phone

Work Phone

Cell Phone

911 Address

Number

Street

City

Postal Code

Apartment:

Joint Custody

Last Name

First Name

Home Phone

Work Phone

Cell Phone

911 Address

Number

Street

City

Postal Code

Apartment:

Joint Custody Sitter

Last Name

First Name

Home Phone

Work Phone

Cell Phone

911 Address

Number

Street

City

Postal Code

Apartment:

Section D: Out of School Attendance Boundary

Only complete this section if the addresses entered above are outside of the boundary for the requested School

Comments:

Section E: Medical Information

Reason for Special Transportation

Is the student restricted in his/her activities at school?

If yes, please explain any reduction in physical activities and/or other restrictions while at school.

Is this student capable of walking the above distance to/from school or bus stop? If no, please complete the following section.

a. Explain the nature of the medical condition, in detail.

b.Transportation is neccessary for the following period:

From

Is your child Anaphylactic? Is your child Diabetic?

Student Photo

Emergency Contacts

		Name:	(H)	(W)	(C)
	1.

		Name:	(H)	(W)	(C)
	2.

		Name:	(H)	(W)	(C)
	3.

Anaphylaxis Emergency Treatment Plan

Student has a potentiall life-threatening allergy (anaphylaxis) to the following:

Peanut

Tree Nuts

Wheat

Egg

Milk

Latex

Insect Stings (bees/wasp)

Other:

Medical:

Parent/Guardian grants permission for a copy of this form to be given to their child's driver, where applicable.
All drivers have First Aid/CPR and EpiPen® training.

Signs and Symptoms

A person experiencing an anaphlyactic reaction might have one of the following symptoms:
F.	Face: rash, itchiness, redness, swelling of face and tongue.
A.	Airway: trouble breathing, swallowing or speaking.
S.	Stomach: stomach pain, vomiting, diarrhea.
T.	Total: hives, rash, itchiness, swelling, weakness, pallor (palenesss) sense of doom, loss of consciousness.

Treatment: Think - A.C.T

Administer the epinephrine auto injector (EpiPen®) IMMEDIATELY, at the first sign of a reaction, in conjunction with the child's contact with their life threatening allergen.

Administer the injection in the lateral (outer) location on the thigh. Inject and count for 10 seconds. Remove the EpiPen®, check needle is showing and massage area for 10 seconds.

A second dose may be administered 10 - 15 minutes or sooner, if symptoms have not improved or worsened.

Call 911. When informing the dispatcher use the term 'ANAPHYLACTIC' reaction.

Transport to hospital by ambulance. Student must go to the hospital even if symptons are mild or have stopped. Call parents/guradians.

Diabetes Hypoglycemia Emergency Action Plan

Classroom Teacher:

Signs and Symptoms

Sweating

divembling

Dizziness

Mood changes

Hunger

Headaches

Blurred vision

Exdiveme tiredness/paleness

Other, please specify:

Optimum Level (Range) of Blood Sugar is:

Location of Sugar Treatment

With Student

Other, please specify:

WHEN IN DOUBT - TREAT

Select one treatment, provided by parent, from the following:

6 oz. (125 ml) of fruit juice/drink (junior juice box) OR

3 - 4 tsp. (10 - 15 ml) of sugar (3 - 4 parckets) OR

6 oz. (125 ml) of regular pop (not diet type) OR

3 - 4 tsp. (10 - 15 ml) of honey OR

4 - 5 glucose tablets OR

Other:

CALL PARENTS TO INFORM THEM

Wait 10 - 15 minutes. If there is no improvement, repeat the above treatment.

DO NOT LEAVE THE STUDENT ALONE!

If the student is unconscious, having a seizure or unable to swallow DO NOT give food or drink.

*Roll the student on his/her side

*Call 9-1-1

*Inform parents/guardians

Section F: Guardian at Stop Contract

Guardian at Stop Contract

RCJTC Responsibility:

RCJTC shall provide safe and reliable transportation to and from school for eligible students. We recognize the vital role parents play in the safe transportation of students, and have developed operating procedures to identify the responsibilities for communication and co-operation between the parents/guardians, school, and transportation services.

Supervision:

a) Prior to their first ride, parents/guardians with the help of school staff will arrange "bus buddies" for students who require them.

b) Parents/Guardians or a responsible designate are to accompany and remain with the student until picked up by the transportation vehicle. No JK/SK student should be left unattended at a pick up point.

c) School staff will sort and load students and check attendance to ensure all students are accounted for

d) Parents/Guardians or a responsible designate should be on time at the drop off point to receive their JK/SK student.

e) Drivers will not knowingly leave a child unattended at a stop, but recognize that a spare driver may not know your child or with a large group there is not always acknowledgement of who goes with whom.

As a parent/guardian requesting transportation services for my child who is named above, I hereby agree to abide by RCJTC Transportation Policy P.01, section 9 'Parents/Guardians Responsibilities Regarding Busing'. I further realize that the services provided are a privilege, not a right and may be suspended or withdrawn in the event I and/or my child fail to abide by the rules.

I have been made aware of and fully understand that I am responsible to receive my child at the end of the day or to provide a responsible designate who is named below and that it is my sole responsibility to inform the RCJTC in a timely manner of address changes, drop off changes, health changes or any other changes that may affect the safe transportation of my child.

Responsible Designate

Complete this section if someone other than yourself is permitted to receive your child at the end of the day.

I authorize those person(s) named below to receive my child (named above) in my absence and I understand that it is the responsibility of me or my designate listed below to receive my child at the designated stop.

Please specify all the details for at least one designate

Designate 1

Name:

Address:

Phone Number:

Designate 2

Name:

Address:

Phone Number:

Please accept the following terms...
I fully understand that RCJTC may enact emergency procedures if I or my assigned designate is not available to receive my child from Transportation Services and/or if the emergency contact(s) named above is/are not available.

All reasonable efforts are made by Board and RCJTC staff and transportation operators to ensure the safety of every child involved in transportation services. Parents/guardians play a key role in ensuring the safety of their child by providing accurate information and ensuring each child is met by a responsible designated person at the end of every day.

Submitted by I acknowledge that transportation procedures will apply.

Last Name

First Name

Request that auto fills subsequent requests for siblings and boundary checks

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

Parent/Guardian

Sitter

Joint Custody

Joint Custody Sitter

Reason for Special Transportation

Student Photo

Emergency Contacts

Anaphylaxis Emergency Treatment Plan

Student has a potentiall life-threatening allergy (anaphylaxis) to the following:

Signs and Symptoms

Treatment: Think - A.C.T

Diabetes Hypoglycemia Emergency Action Plan

Signs and Symptoms

Optimum Level (Range) of Blood Sugar is:

Location of Sugar Treatment

WHEN IN DOUBT - TREAT

CALL PARENTS TO INFORM THEM

DO NOT LEAVE THE STUDENT ALONE!

Guardian at Stop Contract

RCJTC Responsibility:

Supervision:

Responsible Designate

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