Special Needs Transportation Form 2019-2020 Special Needs Transportation Form 2019-2020 Student InformationStudent's Name* First Last Preferred Student Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleHome Address* Street Address City ZIP Code Primary Contact Type*Click the drop down arrow for options.SelectParentGuardian (non-parent)Facility ContactPrimary Contact* First Last Primary Phone*Secondary Contact Type*Click the drop down arrow for options.SelectParentRelativeGuardian (non-parent)Facility ContactSecondary Contact* First Last Secondary Phone*Grade Level*PreschoolK-67-12Specialty SchoolsSelect Preschool Elementary School*Click drop down arrow to find the list of all Preschool Elementary Schools.SelectBELMONT-PREBONNEVILLE-PRECENTENNIAL-PREDEERFIELD-PREEAGLE VALLEY-PREGENEVA-PREGIANT STEPS - EAST (at Foothill)GIANT STEPS - WEST (at Thunder Ridge)GREENWOOD-PREHARVEST-PRELEGACY-PRELEHI-PRELIBERTY HILLS-PRELINDON-PREMOUNTAIN TRAILS-PRENORTH POINT-PRENORTHRIDGE-PREPONY EXPRESS-PRESAGE HILLS-PRESEGO LILY-PRESPRINGSIDE-PRESUNCREST-PRETHUNDER RIDGE-PRETRAVERSE MOUNTAIN-PREWINDSOR-PRESelect Elementary School*Click drop down arrow to find the list of Elementary Schools for K-6. SelectAlpine ElementaryAspen ElementaryBarratt ElementaryBelmont ElementaryBlack Ridge ElementaryBonneville ElementaryBrookhaven ElementaryCascade ElementaryCedar Ridge ElementaryCedar Valley ElementaryCentennial ElementaryCentral ElementaryCherry Hill ElementaryDeerfield ElementaryDry Creek ElementaryEagle Valley ElementaryEaglecrest ElementaryFoothill ElementaryForbes ElementaryFox Hollow ElementaryFreedom ElementaryGeneva ElementaryGreenwood ElementaryGrovecrest ElementaryHarvest ElementaryHidden Hollow ElementaryHighland ElementaryLegacy ElementaryLehi ElementaryLiberty Hills ElementaryLindon ElementaryManila ElementaryMeadow ElementaryMount Mahogany ElementaryMountain Trails ElementaryNorth Point ElementaryNorthridge ElementaryOrchard ElementaryOrem ElementaryPony Express ElementaryRidgeline ElementaryRiver Rock ElementaryRiverview ElementaryRocky Mountain ElementarySage Hills ElementarySaratoga Shores ElementaryScera Park ElementarySego Lily ElementarySharon ElementaryShelley ElementarySnow Springs ElementarySpringside ElementarySuncrest ElementaryThunder Ridge ElementaryTraverse Mountain ElementaryValley View ElementaryVineyard ElementaryWestfield ElementaryWestmore ElementaryWindsor ElementarySelect Secondary School*Click drop down arrow to find the list of Secondary schools.SelectAmerican Fork Junior HighCanyon View Junior HighFrontier Middle SchoolLake Mountain Middle SchoolLakeridge Junior HighLehi Junior HighMountain Ridge Junior HighOak Canyon Junior HighOrem Junior HighPleasant Grove Junior HighTimberline Middle SchoolVista Heights Middle SchoolWillowcreek Middle SchoolAmerican Fork High SchoolCedar Valley High SchoolLehi High SchoolLone Peak High SchoolMountain View High SchoolOrem High SchoolPleasant Grove High SchoolPolaris High SchoolSkyridge High SchoolTimpanogos High SchoolWestlake High SchoolSelect Specialty School*Click drop down arrow to find the list of Specialty schools.SelectDan PetersonHorizonATEC EastATEC WestDoes your student require bus transportation?*YesNoTransportation NeedsStudent Mobility*WheelchairAble to WalkStudent Considerations*Check all that apply Verbal Disability Hearing Disability Intellectual Disability Physically Disabled Vision Disability Emotional Disturbance Developmental Delay Other consideration Additional ConsiderationsEnter additional informationWhat amount of supervision is needed for your student on the bus?*LowMediumHighProcedural safeguards for medical or behavioral concerns*Select all that apply Seizure Shunt Feeding tube Fragile Bones or other orthopedic Significant swallowing difficulty or choking concern. Medication side effects Allergy Asthma Alternate communication Other None Additional SafeguardsWould your student benefit from a safety vest?*YesNoPreschool Safety Vests In order to ensure the safety of your preschooler, Alpine School District transports all preschool students in a safety vest. If you have any questions or concerns please contact Transportation.Student Pickup/Drop off DetailsWill your student be picked up and dropped off at the same location before and after school?*YesNo Check this box if the pickup/drop off location is a care facility Care Facility Name*Care Facility Phone*Contact Name*Name of person at the care facility that is responsible for the student.Pickup/Drop off Location* Street Address City Pickup Location* Street Address City Check the box if the Pickup location is a care facility Care Facility Name*Contact Name*Name of person at the care facility that is responsible for the student.Care Facility Phone*Drop off Location* Street Address City Check this box if the dropoff location is a care facility Care Facility Name*Contact Name*Name of person at the care facility that is responsible for the student.Care Facility Phone*Can this student be discharged from the bus without anyone waiting to receive them?*YesNoAlternate Drop off Contact*If you are not home and cannot be reached by phone, where nearby your home should your student be dropped off? This person will be contacted to receive your student. First Last Alternate Drop off Phone*Alternate Drop off Address* Street Address City Other than the parent or guardian who may receive the student from the bus? NOTE: in order for the student to be released to any individual, their name must be on this sheet.*Please list full names of all individuals separated by a comma.Emergency Contact PersonOther than parent/guardianEmergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Relationship*SelectParentAunt/UncleGrandparentNeighbor/FriendOtherAdditional InformationPlease list any additional needs or considerations that our transportation staff need to be aware of.Notification to Parent/ Guardian If there are any changes in your child’s medical or behavioral status which you believe may merit changes in staffing, precautions to be taken, interventions, restraint, or any other procedure discussed above, contact the Special Education Department at (801) 610-8410. A new address requires at least a seven (7) school day notification to the respective Transportation Department office. East office (801) 610-8850. West office (801) 610-8852. I also understand that the Alpine School District has implemented the safety measure of securing all pre-school students in safety vests while on the bus. Further, in the event of an accident, injury, or serious illness, I give permission for Alpine School District Personnel to secure medical aid or transportation to a medical facility. I understand that neither the Alpine School District nor the individual responsible for obtaining medical aid will be responsible for expenses incurred. I give permission for Alpine School District Personnel to transport my student as recommended in the Individual Education Plan (IEP). SignatureSignature Name* First Last Email Enter Email Confirm Email This iframe contains the logic required to handle Ajax powered Gravity Forms.