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HUNTERDON COUNTY
Educational Services Commission
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Special Needs Request Form

Special Needs Request Form

Transportation cannot begin without written notification to the commissioner.

  
*Email Address
Date
*School Year
Summer
Miles
*District
*Contact Name
*Phone Number
*Student Name
*Address
(if different)
*Birth Date
Classification
Sex
Grade
*Parent/Guardian
*Phone Number
Cell Number
Em Contact 1
Em Phone 1
Em Contact 2
Em Phone 2
Student can be left at home with no supervision
Special Needs Transport in Wheelchair
Leg Braces/Crutches
Requires Close Supervision
Requires Medical Attention
Requires Aide
Requires Car Seat
Requires Restraint
Seizures
Controlled Medication
Allergies
Medications
*General Statement of Need
Behavior Patterns
Behavior Management Recommendations
*School to Attend
School Address
School Contact
School Phone
School Hours
*Start Date
*End Date
Days Monday
Tuesday
Wednesday
Thursday
Friday
Route A.M.
P.M.
* fields are required
Required! Please re-type the word below into the blank field.
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