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Douglas County School SystemSpecial Education Transportation Request FormSchool Year _________ - _________Student ____________________________________Date of Birth_____________________________Parent/Guardian _____________________________Primary Phone ___________________________Home Address _______________________________Work Phone ________________________________________________________________________Email ___________________________________right4741545Special Needs Transportation Rules and RegulationsI verify that all contact and address information is correct. I have reviewed a copy of the special needs transportation rules and regulations.Parent/Guardian Name (Please Print): ______________________________ Date: __________________Parent/Guardian Signature: _____________________________________________________________00Special Needs Transportation Rules and RegulationsI verify that all contact and address information is correct. I have reviewed a copy of the special needs transportation rules and regulations.Parent/Guardian Name (Please Print): ______________________________ Date: __________________Parent/Guardian Signature: _____________________________________________________________3104515248285PM TransportationAddress: _______________________________________________________________________Contact ________________________________ Phone _________________________________00PM TransportationAddress: _______________________________________________________________________Contact ________________________________ Phone _________________________________left245948AM TransportationAddress: _______________________________________________________________________Contact ________________________________ Phone _________________________________00AM TransportationAddress: _______________________________________________________________________Contact ________________________________ Phone _________________________________left1866638School InformationAssigned School ___________________________Base School ____________________________Date Requested to Begin ____________________Transportation in IEP/504: ____ Yes ____ No(Please allow five (5) days from request receipt by Transportation)00School InformationAssigned School ___________________________Base School ____________________________Date Requested to Begin ____________________Transportation in IEP/504: ____ Yes ____ No(Please allow five (5) days from request receipt by Transportation)31292965943468FOR TRANSPORTATION OFFICE USE ONLY______________________________ Bus Number Date_______________________________________Special Education Transportation Router00FOR TRANSPORTATION OFFICE USE ONLY______________________________ Bus Number Date_______________________________________Special Education Transportation Routerleft5941060FOR SCHOOL/CENTRAL OFFICE USE ONLY______________________________________Special Education Teacher Date______________________________________Special Education Coordinator Date00FOR SCHOOL/CENTRAL OFFICE USE ONLY______________________________________Special Education Teacher Date______________________________________Special Education Coordinator Dateleft2805164Medical InformationMedical or Health Problems _________________________________________________________________________________________________________________________________________________Does Student Have Wheelchair: _____ Yes _____ NoDoes Student Have Seizures: ____ Yes ____ NoWeight of Student: 22-40 LBS ______Star-Seat Needed: ____ Yes ____ No41-90 LBS ______Safety Vest Needed: ____ Yes ____ No91+ LBS ______Vision Impaired/Blind: ____ Yes ____ No Deaf/Hard of Hearing: ____ Yes ____ NoOther Mobility Devices _________________________________________________________________00Medical InformationMedical or Health Problems _________________________________________________________________________________________________________________________________________________Does Student Have Wheelchair: _____ Yes _____ NoDoes Student Have Seizures: ____ Yes ____ NoWeight of Student: 22-40 LBS ______Star-Seat Needed: ____ Yes ____ No41-90 LBS ______Safety Vest Needed: ____ Yes ____ No91+ LBS ______Vision Impaired/Blind: ____ Yes ____ No Deaf/Hard of Hearing: ____ Yes ____ NoOther Mobility Devices _________________________________________________________________Emergency Contact: __________________________Phone Number ___________________________ ................
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