Out of District Special Education Transportation Application
**ONLY STUDENTS WHO REQUIRE TRANSPORTATION SERVICES BASED ON THEIR IEP QUALIFY FOR SPECIAL EDUCATION TRANSPORTATION AND ARE BEING TRANSPORTED OUT OF DISTRICT**
This form is for Special Education students only. The Regular Education Application can be found on the
beverlyschools.org
website or through this link:
https://docs.google.com/forms/d/e/1FAIpQLSeqDLny4_d15kmDpn0dhHEJPv2dgI6L_ZN8DDRRLBxHC9H1eg/viewform
The Special Education Application for Special Education students being transported within Beverly can be found here:
http://beverlyschools.org/resources/transportation/Special_Education_Transportation_Application
* Required
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Street Address
*
Your answer
Primary Phone
*
Example: xxx.xxx.xxxx
Your answer
Alternate Phone
Example: xxx.xxx.xxxx
Your answer
School Name and Address
*
Your answer
Grade
*
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
AM, PM, or Both Ways
*
Both Ways
AM Only
PM Only
Monitor Required
Yes
No
Clear selection
Special Instructions
Your answer
Requested Start Date
MM
/
DD
/
YYYY
IEP Signed by Parent/Guardian
MM
/
DD
/
YYYY
**ALL TRANSPORTATION REQUESTS WILL HAVE A 2 DAY WAITING PERIOD BEFORE TRANSPORTATION WILL BEGIN. THE 2 DAY PERIOD IS FROM THE DATE THIS FORM IS RECEIVED.***
**IF YOUR CHILD IS PICKED UP OR DROPPED OFF SOMEWHERE OTHER THAN YOUR HOME ADDRESS, PLEASE PROVIDE THE FOLLOWING INFORMATION:
Daycare Provider Name
Your answer
Daycare Provider Address
Your answer
Daycare Provider Phone Number
Example: xxx.xxx.xxxx
Your answer
Days of the week at this location
Monday
Tuesday
Wednesday
Thursday
Friday
Pickup/Drop off times at this location
Morning Pickup
Afternoon Drop Off
Both
IF THE ABOVE INFORMATION IS NOT FILLED OUT, WE WILL PICK UP AND DROP OFF YOUR CHILD AT YOUR HOME ADDRESS
Parent/Guardian Email Address:
Your answer
Parent/Guardian Signature (Typed)
*
By signing this, we verify that we have read the Terms and Conditions for Bus Riding Privileges and agree to do all that we can to see that our child complies with bus rules. Find the Terms and Conditions here:
https://drive.google.com/file/d/1HSegJDoH2qjchLVXzxdEdjAATuj_hLCr/view?usp=sharing
Your answer
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