Special Needs Transportation Form 2024-2025

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Student Information

Student's Name*

First Last Preferred

Student ID Number

This is the number your student uses for lunch. If you don't know your student's ID number, it can be found by logging into Skyward and looking at your student's profile, or by calling your student's school. If you have a preschool student, you can call the school to get your student's ID number.

Student Birth Date*

Gender*

Male

Female

Home Address*

Street Address City ZIP Code

Primary Contact Type*

Click the drop down arrow for options.

Primary Contact*

First Last

Primary Phone*

Secondary Contact Type*

Click the drop down arrow for options.

Secondary Contact*

First Last

Secondary Phone*

Grade Level*

Preschool

K-6

7-12

Specialty Schools

Select Preschool Elementary School*

Click drop down arrow to find the list of all Preschool Elementary Schools.

Select Elementary School*

Click drop down arrow to find the list of Elementary Schools for K-6.

Select Secondary School*

Click drop down arrow to find the list of Secondary schools.

Select Specialty School*

Click drop down arrow to find the list of Specialty schools.

Does your student require bus transportation?*

Yes

Transportation Needs

Student Mobility*

Wheelchair

Able to Walk

Other

Student Considerations*

Check all that apply

Verbal Disability

Hearing Disability

Intellectual Disability

Physically Disabled

Vision Disability

Emotional Disturbance

Developmental Delay

Other consideration

Additional Considerations

Enter additional information

What amount of supervision is needed for your student on the bus?*

Low

Medium

High

Procedural 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 Safeguards

Does your student have a Behavior Intervention Plan?*

Yes

Does your student have a Health Care Plan?*

Yes

Would your student benefit from a safety vest?*

Yes

Preschool 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 Details

Will your student be picked up and dropped off at the same location before and after school?*

Yes

Please select pickup/drop off location*

Please Specify*

Is this a split custody situation?*

Yes

Hidden

Check this box if the pickup/drop off location is a care facility

Facility/Sitter Name*

Facility/Sitter 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

Please select pickup location*

Please Specify*

Is this a split custody situation?*

Yes

Hidden

Check the box if the Pickup location is a care facility

Facility/Sitter Name*

Facility/Sitter Phone*

Contact Name*

Name of person at the care facility that is responsible for the student.

Drop off Location*

Street Address City

Please select drop off location*

Please Specify*

Is this a split custody situation?*

Yes

Hidden

Check this box if the dropoff location is a care facility

Facility/Sitter Name*

Facility/Sitter Phone*

Contact Name*

Name of person at the care facility that is responsible for the student.

Can this student be discharged from the bus without anyone waiting to receive them?*

Yes

You are agreeing to allow your student to be discharged from the bus without anyone to receive them. Please be advised that this arrangement will only be honored while it is deemed safe by the school, the Special Education department, and the Transportation department. Please ensure that your student has a safe pathway from the bus to their home, and can safely enter the home without assistance. If safety concerns do arise then this agreement may have to be revisited, and someone may have to be present to receive your student.

Acknowledgement*

I understand the safety concerns and agree to have my student discharged from the bus without anyone waiting to receive them.

Alternate 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 Person

Other than parent/guardian

Emergency Contact Name*

First Last

Emergency Contact Phone*

Emergency Contact Relationship*

Additional Information

Please 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) 610-8200.
A new address requires at least a ten (10) 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).

Notificación para los padres y guardian legal
Si hay algún cambio en el estado de salud o de comportamiento de su hijo que usted cree que requiere ciertos cambios en el personal, precauciones que deben tomarse, intervenciones, restricciones o cualquier otro procedimiento que se haya mencionado anteriormente, póngase en contacto con el Departamento de Educación Especial (801) 610-8200.
Un cambio de dirección requiere por lo menos diez (10) días de previa notificación al Departamento de Transporte al teléfono
Este (801) 610-8850.
Oeste (801) 610-8852.
También entiendo que el Distrito Escolar de Alpine ha implementado la medida de seguridad que todos los estudiantes preescolares deben llevar chalecos de seguridad mientras viajen en el autobús. Además, en caso de accidente, lesión, o seria enfermedad, doy permiso al personal del Distrito Escolar Alpine conseguir ayuda médica o el transporte a un centro médico . Entiendo que ni el Distrito Escolar Alpine ni la persona responsable de obtener la ayuda médica es responsable de los gastos incurridos. Como padre, madre o tutor legal (circule uno) del estudiante mencionado, doy permiso al personal del Distrito Escolar de Alpine para que transporte a mi estudiante como se recomienda en el Plan de Educación Individual (IEP).

Signature

Signature Name*

First Last

Enter Email Confirm Email