Individualized Transportation Request
Email address *
The Corvallis School District Transportation Department can be contacted at 541-757-5877 or email Becky Weeks at becky.weeks@corvallis.k12.or.us
Reason for Transportation Service Request: *
How does this student qualify for individualized transportation services?
If the the student has transportation as a related service as part of an IEP, IFSP, or 504 plan, please email a copy of the document to becky.weeks@corvallis.k12.or.us . If the student qualifies in more than one way, list the other qualifier in the last question on this form.
Does this student require door to door service? *
If the answer is yes, please provide the reason there is a need for door to door service.
Your answer
Start Date: *
Allow at least three full business days for processing prior to start date.
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End Date:
If you have an end date indicate it below or if this transportation is anticipated until the End of the Year list EOY.
Your answer
STUDENT INFORMATION
Student Last Name: *
Your answer
Student First Name: *
Your answer
Database Number (if available - any District employee submitting request should include DBN.)
Your answer
Date of Birth: *
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Home Address: (#, Street, City, Zip)
Your answer
FAMILY CONTACT INFORMATION
Name of Primary Parent/Guardian: *
Your answer
Relationship of Primary Parent/Guardian to student: *
Your answer
Phone Number(s) of Primary Parent/Guardian: *
Your answer
Second Adult Contact Name: *
Your answer
Relationship of Second Adult Contact to Student: *
Your answer
Phone Number(s) for Second Adult Contact: *
Your answer
Third Adult Contact Name:
Your answer
Relationship of Third Adult Contact to Student:
Your answer
Phone Number(s) for Third Adult Contact:
Your answer
SCHOOL INFORMATION
School: *
If "Other" is chosen, - Include address.
Grade:
Program: *
Daily Class Schedule (Days & Hours): *
Name, Title and Phone Number for Case Manager: *
Your answer
Name & Phone Number for point/contact person at your school for this student: *
Your answer
Name & Phone Number for person submitting this form: *
Your answer
INDIVIDUAL STUDENT NEEDS
Does this student have an Emergency Protocol or Behavior Plan? *
If yes, email copy of document to becky.weeks@corvallis.k12.or.us
Allergies?
List all allergies and forward any protocols to becky.weeks@corvallis.k12.or.us
Your answer
Height & Weight:
This information is usually used to identify booster / car seat requirements. If we need to arrange transportation through a taxi service, we will not be able to proceed without this information for preschool and elementary aged students.
Your answer
Student Mobility Information *
Does the student require an aide or nurse present while being transported?
May the student be left unattended at the school? *
May the student be left unattended at the drop off location? *
Details / Special Concerns:
Your answer
TRANSPORTATION DETAILS
Provide details about students alternate pick-up and drop off locations in the MULTIPLE LOCATIONS box. Multiple programming schedules can be documented a the end of the form.
Pick up schedule. Which days apply? *
Required
Where does your student need to be picked up? *
Include street address, city & zip for any location other than HOME. Note that any alternate location listed must have contact information listed in the "Adult Contact" section of this form.
Your answer
MULTIPLE LOCATIONS: If your student is going to be picked up at different locations during the week, please detail the schedule below.
Example: Monday- Home, Tuesday-Daycare (include address), etc.
Your answer
Drop off schedule. Which days apply? *
Required
Where does your student need to be dropped off? *
Include the street address, city & zip for any location other than HOME. Note that any alternate location listed must have contact information listed in the "Adult Contact" section of this form.
Your answer
MULTIPLE LOCATIONS: If your student is going to be dropped off at different locations during the week, please detail that information below.
Example: Monday & Wednesday - Home; Tuesday - Daycare (include address), etc.
Your answer
If your student qualifies for McKinney Vento or DHS Foster, do they need transportation from after school program to home?
Is your student receiving transportation for more than one program or attending more than one school? If so, please detail the schedule/locations below:
Example: Attends Dixie/Speech M & W 10-11am (beginning 9/12/18); Attends OSUCDC Bates Hall T, TH, F 9am-12am (beginning 10/1/18), etc.
Your answer
What additional information do we need to successfully transport this student? (IE: Is the families home language something other than English?)
Your answer
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