By Cynthia Taylor,2014-08-28 21:22
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    School Year: 200 / 200

     New Change (please circle the change on form) Cancellation Empty Seat

     Empty Seat-Principal Signature ____________________ School Bus Wheelchair Bus TTC PARENT USE Please complete this section, Page 2 and return to school

    Student Surname: First Name: Health Card Number:

    Date of Birth: dd mm yy Parent / Guardian E-mail Address(es): (if available) Male Female Home Address: Postal Code: Home Phone: Apt. #:

Mother/Legal Guardian Name: Business Phone:

    Business Phone: Father/Legal Guardian Name:

    Emergency Contact: Phone: (Ensure emergency contact is someone other than parent)

     Transportation location for pick up prior to school: School/Stop pick-up or drop-off for Regular, French Immersion or Gifted students

     Transportation location for drop off at dismissal:

     Page 2 SCHOOL USE ONLY Please complete this section and fax to Transportation Office (416) 394-3806 Destination School Name: School Address: Phone Number:

    School Code: Program: Program Code: Trillium #: Grade:

     Accurate Bell Times are Imperative Class Start Time: Class Dismissal Time: Program Specifications (please provide days and times):

    Date Transportation to Begin: End Date:

Special Transportation Requirements/Instructions:

    (i.e., Individual Transportation re Behaviour/Health; Car Seat; Safety Vest; Accompanied by nurse or other;

    If the student requires school bus transportation outside the Policy, at what cognitive grade level does he/she function? __________________ __________________ _________ Signed by Sending School


     Big Bus Van Mini Van W/C Van Taxi TTC

     _______________ ___________

     (Carrier) (Company)

     Approved Denied: (Distance / Optional Attendance)

Transportation Supervisor Signature: Date:

Date sent to Planning: Date sent to School:


    **TTC Tickets do not require medical information

    Student Surname: First Name: School:

    Does the student have any history of allergy and/or drug-medicine reaction? If yes, explain. Yes No

    Is the student on regular medication? If yes, explain (name medication and dosage): Yes No

What medication will be sent with the student to school?

    Does the student have any present/previous major illness or injury that might have a Yes No persisting effect? If yes, explain.

Does the student have any form of:

    Diabetes Yes No Epilepsy/Seizures Yes No Asthma Yes No Deafness Yes No Vision Difficulty Yes No Language/Communication Difficulty Yes No Heart Disease Yes No Emotional/Behavioural Problems Yes No Shunt Yes No Atlantoaxial Instability Yes No Other: Please explain :

    What other information would you suggest that might be required by the school or hospital in case of emergency?

     In case of emergency, permission is hereby given to the Toronto District School Board to release the above information to a medical practitioner. The pupil is to be taken to the nearest hospital for examination and, if necessary, x-rays. In addition, this information will be shared with the transportation carrier. Personal information contained on this form or general information collected on behalf of the Toronto District School Board regarding the student is collected under the authority of the Education Act and in compliance with sections 14, 31 and 32 of the Municipal Freedom of Information and Protection of Privacy Act and will be used for education, transportation and health and safety purposes.

    S P E C I A L T R A N S P O R T A T I O N R E Q U I R E M E N T S

    Does the student travel to/from school in a wheelchair? If yes, what type of wheelchair?

     Yes No Motorized Highback

     Does the student travel with a walker Yes No Manual Reclining

    Does the student travel to/from school in an infant toddler seat? Yes No Car Seats: May be used on 20 passenger buses for daily home to school transportation. Car Seats must be used for students who

    require them because of their medical condition. If student is under 40 lbs., please indicate weight . Booster Seats: Mandatory by law if student is riding in a minivan or taxi. If student is between 40 and 80 lbs., under 145 cm tall

    and up to 8 years of age, a booster seat is required.

    All car and booster seats must be CSA approved and tethered into the school vehicle as required by the Ministry of Transportation

    before transportation can start. Trained staff from the bus company will inspect and install the car seat or booster seat.

     Parent/Guardian must provide the car or booster seat and must leave them on the vehicle for the school year.

    Does the student require a safety vest? If yes, please provide waist measurement with student wearing light jacket.

     Yes No Waist

    Please provide any additional information about the student’s transportation requirements.

    Please note: It is the parent/guardian’s responsibility to keep this information up-to-date.

    Date:___________________ Parent/Guardian Signature:_______________________________________

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