Special Education Transportation Form

Special Education Transportation Form

Greater Jasper Consolidated Schools - 1520 St. Charles Street Jasper, IN 47546 PHONE (812) 482-1801 - FAX (812) 482-3388
Submitter Email
example@example.com
Student ID #
Student Full Name

First NameLast Name
Student DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Gender
Student Grade
Student School
If PreSchool - Please indicate AM or PM.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone Number #1
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Phone Number #2
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Teacher of Record
School Year
Date Transportation is Requested to Begin (Routing will take between 3-5 days to complete). If this is an AR update, use today's date.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What days will the student need transportation?
Transportation Needed
Pickup Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pickup Contact Name

First NameLast Name
Relation to Student

Other
Pickup Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Drop Off Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Drop Off Contact Name

First NameLast Name
Relation to Student

Other
Drop Off Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Does the student have permission to be picked up/dropped off without an adult present?
Sign here if your student is able to be picked up without an adult present.
The undersigned parent(s) or legal guardian does hereby grant and authorize the Greater Jasper Consolidated Schools and any employee thereof, to obtain at the expense of the the undersigned, any medical services, including but not limited to x-ray examination, anesthetic, surgical treatment of any hospital service, for the named student in the event said student suffers illness or accident at a time when the undersigned cannot be contacted. It is my request that such treatment shall be rendered by the Primary Care Physician listed or physician "on call" at the hospital emergency room. This medical consent is given in advance of treatment to encourage and authorize the school and employees and the named physician to exercise their judgment in the best interest of my student.
If verbal permission is given by a guardian for a staff member to sign the form, please include name of guardian, name of staff member signing, and date permission is given.
Does a Health Care Action Plan need to be in place?
If YES, please upload.

Cancelof
Does a Bus Behavior Plan need to be in place?
If YES, please upload.

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Additional Information/Comments
Should be Empty: