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Request for Transportation (Dynamic Form)

Section A: Student Information

Parent/Guardian

Physical or Residential Address (where the student resides)

Are either parents of this student of the Catholic Faith?
Transportation may be provided to and/or from home/sitter/joint custody location, if the arrangement is permanent (5 days per week) and this location can be safely scheduled into the regular routes and is within the pupil's home school attendance boundary.










Section B: Stop Location Information A maximum of two (2) weeks or a minimum of two (2) days notice is required to safely implement.

  
Section C: Alternate Address Information

Sitter

Alternate Address (where the student needs to go, other than home)

Joint Custody

Alternate Address (where the student needs to go, other than home)

Joint Custody Sitter

Alternate Address (where the student needs to go, other than home)

Alternate

Alternate Address (where the student needs to go, other than home)
Section D: Out of School Attendance Boundary Only complete this section if the addresses entered above are outside of the boundary for the requested School



Section E: Medical Information

Reason for Special Transportation


If yes, please explain any reduction in physical activities and/or other restrictions while at school.



If no, please complete the following section.

a. Explain the nature of the medical condition, in detail.


b.Transportation is neccessary for the following period:
From:
  
To:
  




Student Photo

Emergency Contacts

1.
2.
3.

Anaphylaxis Emergency Treatment Plan

Student has a potentiall life-threatening allergy (anaphylaxis) to the following:



Signs and Symptoms

A person experiencing an anaphlyactic reaction might have one of the following symptoms:
F.      Face: rash, itchiness, redness, swelling of face and tongue.
A.      Airway: trouble breathing, swallowing or speaking.
S.      Stomach: stomach pain, vomiting, diarrhea.
T.      Total: hives, rash, itchiness, swelling, weakness, pallor (palenesss) sense of doom, loss of consciousness.

Treatment: Think - A.C.T

Administer the epinephrine auto injector (EpiPen®) IMMEDIATELY, at the first sign of a reaction, in conjunction with the child's contact with their life threatening allergen.

Administer the injection in the lateral (outer) location on the thigh. Inject and count for 10 seconds. Remove the EpiPen®, check needle is showing and massage area for 10 seconds.

A second dose may be administered 10 - 15 minutes or sooner, if symptoms have not improved or worsened.

Call 911. When informing the dispatcher use the term 'ANAPHYLACTIC' reaction.

Transport to hospital by ambulance. Student must go to the hospital even if symptons are mild or have stopped. Call parents/guradians.

Diabetes Hypoglycemia Emergency Action Plan

Classroom Teacher:

Signs and Symptoms

Optimum Level (Range) of Blood Sugar is:

Location of Sugar Treatment

WHEN IN DOUBT - TREAT

Select one treatment, provided by parent, from the following:
6 oz. (125 ml) of fruit juice/drink (junior juice box) OR
3 - 4 tsp. (10 - 15 ml) of sugar (3 - 4 parckets) OR
6 oz. (125 ml) of regular pop (not diet type) OR
3 - 4 tsp. (10 - 15 ml) of honey OR
4 - 5 glucose tablets OR
Other:

CALL PARENTS TO INFORM THEM

Wait 10 - 15 minutes. If there is no improvement, repeat the above treatment.

DO NOT LEAVE THE STUDENT ALONE!

If the student is unconscious, having a seizure or unable to swallow DO NOT give food or drink.

*Roll the student on his/her side
*Call 9-1-1
*Inform parents/guardians
Section F: Guardian at Stop Contract

Acknowledgment

PRSD Responsibility:

PRSD shall provide safe and reliable transportation for students while being transported to and from school. We recognize the vital role parents play in the safe transportation of students, and have developed operating procedures to identify the responsibilities for communication and co-operation between the parents/guardians, school, and transportation services.

Parent Responsibilities:

a) Parents/guardians with the help of school staff and/or the bus driver may arrange "bus buddies" for students who require them
b) It is recommended that Parents/Guardians or a responsible designate accompany and remain with younger student(s) at the bus stop.
c) Parents/Guardians or a responsible designate should ensure students are at the stop 3-5 minutes prior to pick time.  Bus Drivers may leave the stop at the stated time, to ensure students arrive at school in a timely manner.
d) Drivers will not knowingly leave a child unattended at a stop, but recognize that a spare driver may not know your child or with a large group there is not always acknowledgement of who goes with whom.
e) A note is required to be submitted to the school prior to boarding a school bus the child is not registered on.  Bus drivers are not required to transport students who are not registered for their route.
f) No person shall bring on the bus the following item(s):  animals (except “guide dog”), firearms, explosives, combustible materials or substances or anything of dangerous or objectionable nature or that might endanger the lives or safety of persons in the bus.


As a parent/guardian requesting transportation services for my child who is named above, I hereby agree to abide by PRSD Transportation Policy 8.31, section 'School Bus Rider Policy'. I further realize that the services provided are a privilege, not a right and may be suspended or withdrawn in the event I and/or my child fail to abide by the rules.

I have been made aware of and fully understand that I am ultimately responsible to get my child to and from the bus stop safely or to provide a responsible designate. It is my sole responsibility to inform the PRSD in a timely manner of address changes, drop off changes, health changes or any other changes that may affect the safe transportation of my child.

Responsible Designate

Complete this section if someone other than yourself is permitted to receive your child at the end of the day.
I authorize those person(s) named below to receive my child (named above) in my absence and I understand that it is the responsibility of me or my designate listed below to receive my child at the designated stop.

Designate 1
Name: Address: Phone Number:
Designate 2
Name: Address: Phone Number:

I fully understand that PRSD may enact emergency procedures if I or my assigned designate is not available to receive my child from Transportation Services and/or if the emergency contact(s) named above is/are not available.

All reasonable efforts are made by Board and PRSD staff and transportation operators to ensure the safety of every child involved in transportation services. Parents/guardians play a key role in ensuring the safety of their child by providing accurate information and ensuring each child is met by a responsible designated person at the end of every day.
Submitted by I acknowledge that transportation procedures will apply.
Confidentiality Statement In accordance with the Personal Information Protection and Electronic Documents Act, Article 29, Paragraph (2), personal information requested in this form will assist in providing transportation services. The information is gathered in accordance with the Education Act in the Province of Alberta.
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