Email Address (must be entered):
Date: School Year: Not Specified 2006-07 2007-08 2008-09 2009-10 Summer: No Yes Miles:
District: Contact: Ph:
Student Name:
Street Address: Apt:
City: Zip:
Nearest Intersecting Road:
Mailing address (if different):
Birth Date: Classification:
Sex: Not Specified Female Male Grade: Not Specified K PK 01 02 03 04 05 06 07 08 09 10 11 12 Oth
Parent/Guar: Ph: Cell:
Emerg Contact 1: Emerg Phone 1:
Emerg Contact 2: Emerg Phone 2:
Student can be left at home with no supervision: No Yes

Special Needs (check all that apply)
Transport in wheelchair No Yes Leg Braces/Crutches No Yes Requires close supervision No Yes
Requires medical attention No Yes Requires Aide No Yes Requires Car Seat No Yes
Requires Restraint No Yes Height: Weight:
Describe medical needs:
Allergies: Medications:
Seizures: No Yes Controlled Medication: No Yes
General statement of need:
Other Special Needs:
Behavior Patterns:
Behavior Management Recommendations:
School to Attend:
School Address: State: Zip:
School Contact: School Phone:
Start Date: End Date: School Hours:
Days: Mon No Yes   Tues No Yes   Wed No Yes    Thur No Yes    Fri No Yes
Route # A.M. No Yes    P.M No Yes
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