Ulster - Preschool Transportation Plan

Child's Information
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Home School District
Name of Program
Is the Mailing Address different from Home Address?
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Parent/Guardian Information
Parent/Guardian #1
Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to child:
Do you wish to add a second parent/guardian?
Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to child:

Complete this section ONLY IF your child is to be picked up or dropped off at an address other than the home.

Temporary Changes Will Not Be Granted
This request is for:
Pick up Address

Street Address

Street Address Line 2

CityState

Zip Code
Drop off Address

Street Address

Street Address Line 2

CityState

Zip Code
Pick up AND Drop off Address

Street Address

Street Address Line 2

CityState

Zip Code

Emergency Contacts
For the safety of your child, Ulster County requires a minimum of two (2) emergency contacts to whom we may release your child in case we are unable to reach you in an emergency or in case you are unable to meet the bus. Emergency contacts must have transportation and must be sixteen (16) or older and must have a physical, valid form of photo identification (i.e., school/work/state ID, passport, driver’s license, etc.) to present in order to receive your child from the bus. The police department will be notified as a last resort.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Persons authorized to receive child from bus
Name

First NameLast Name
Relationship to Child
Name

First NameLast Name
Relationship to Child
Name

First NameLast Name
Relationship to Child
Name

First NameLast Name
Relationship to Child
Name

First NameLast Name
Relationship to Child
Persons who may NOT receive your child
Name

First NameLast Name
Relationship to Child
Name

First NameLast Name
Relationship to Child

In accordance with the State Education Department Office of Vocational and Educational Services for Individuals with Disabilities, Regulations of the Commissioner of Education, Pursuant to §207, §3214, §4403, §4410 of the Education Law, Part 200 Students with Disabilities §200.16 (e)(5): In developing its recommendation for a preschool student with disability programs and services, the committee must identify transportation options for the student, and encourage parents to transport their child at public expense where cost effective.

When making a selection for Parent Transport, I understand that no exceptions will be made to my selection below (Please refer to the Parent Handbook).
Please check one:
If PMR is selected, Prismatic will contact you regarding the next steps.

Provider Agreement between New York State and Service Providers Under Contract with the County of Ulster (Which is Enrolled in the New York State Medicaid Program)
Based upon a request by the County to participate in the New York State Medicaid Program under Title XIX of the Social Security Act,

First NameLast Name
Parent/caregiver agrees as follows to:

A.
1. (1) Keep any record necessary to disclose the extent of SERVICES the Provider furnishes to recipients receiving assistance under the New York State Plan for Medicaid Assistance.
2. (2) On request, furnish the New York States Department of Health, or its designee, and the Secretary of the United State Department of Health and Human Services, and the New York State Medicaid Fraud Control Unit, any information maintained under paragraph A(1), and any information regarding any Medicaid claims reassigned by the Provider.
3. (3) Comply with the disclosure requirements specified in 42 CFR Part 455, Subpart B.
B. Comply with Title VI of the Civil Rights Act of 1964, Section 504 of the Federal Rehabilitation Act of 1973, and all other State and Federal statutory and constitutional non-discrimination provisions that prohibit discrimination on the basis of race, color, national origin, handicap, age, gender, religion and/or marital status.

C. Abide by all applicable Federal and State laws and regulations, including the Social Security Act, the New York State Social Service Law, Part 42 of the Code of Federal Regulations and Title 18 of the Codes, Rules and Regulations of the State of New York.
Please check one:

Statement of Reassignment
Name of Parent/Caregiver

First NameLast Name
By this reassignment, I agree:
1. To reassign all Medicaid reimbursements to Ulster County for providing medical services billed under the Pre School Supportive Health Services Program (SSHSP).
2. To accept as payment in full the contracted reimbursement rates for covered services.
3. To comply with all the rules and policies as described in your contract with Ulster County.
4. To not bill Medicaid directly for any services billed by Ulster County.
Please check one:

Signature Page
Both Signatures are Required to Validate This Form
Parent/Guardian Signature
Date

MonthDayYear
Date
Program Provider Official Signature
Date

MonthDayYear
Date
Should be Empty: