5.A.30 Appropriate Education

Safe Schools

 

 

Administrative Procedure: Appropriate Education

 

EFFECTIVE DATE:

February 9, 2005

 

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ADMINISTRATIVE PROCEDURE CODE:

5.A.30

AMENDED DATE:

December 10, 2014

Policy Reference

 

 

Legal Reference

 

PSA 221/96/(12)

 

 

 





















The Division is committed to providing learning opportunities for all students. The Division is committed to providing classroom teachers of students with exceptional learning needs with access to related professional learning opportunities

 

Border Land School Division addresses the diversity of its student population through a continuum of instructional supports extending from placement in the regular class with no need for adaptations to education provided in highly specialized settings.  The principles of placement with peers in the most enabling environment and program appropriateness inform placement decisions. The school division will provide parents with the opportunity to participate in decisions that affect students’ education and with the information needed to make informed decisions.

 

Students with intellectual, social, emotional, behavioural, physical and/or psychological needs require special education adaptations, equipment and/or programming to learn and to maximize their potential. Students with special needs will be educated in the most appropriate and enabling learning environments.

Access

 

Students with special needs have access to the same minimum number of hours of instruction as all other students and full participation in the curriculum (Manitoba Regulation 101/95).

 

This includes access to experiential learning opportunities such as assemblies, drama, sports, and school or class field trips. Plans to manage risks and reasonably accommodate special needs for these opportunities shall be made collaboratively by the school team, which may include students, teachers, principals, clinicians, parents and/or division office staff.

 

The Assistant Superintendent, Student Services Coordinator, Transportation Coordinator, Maintenance Coordinator, Principals, resource and classroom teachers, clinicians, parents and Manitoba Education personnel will make reasonable efforts to modify structures, remove barriers, or arrange appropriate transportation (the Human Rights Code).

 

A student shall not be denied educational programming pending the receipt of a pupil file, conduct of any assessment, planning or the preparation of an IEP (Manitoba Regulation 155/05).

 

Schools must begin educational programming within 14 days after the student seeks to be enrolled (Manitoba Regulation 155/05).

 

Placement

 

Placement may refer to:

  • the school the student attends;
  • the classroom the student is placed in;
  • the program(s) the student is enrolled in; and/or
  • the grade level the student is in.

An appropriate placement or learning environment should be chosen on an individual basis for a student with special needs. Educating students with special needs in regular classrooms with their peers in local schools is the preferred placement option in Border Land School Division.

 

Determining the appropriate placement for students with special needs is a shared responsibility between parents/legal guardian, the student, the school team, and the Assistant Superintendent and Student Services Coordinator.

 

In determining the most appropriate placement or learning environment for a student, a student’s team considers the particular needs of the student, available resources and supports, the views of the parents/legal guardian, and what is appropriate and reasonable.

 

Early Identification

 

Early identification refers to the process used to identify children’s exceptional learning needs as early as possible in their education.

 

According to Transition protocols on Guidelines for Early Childhood Transitions to School (http://www.gov.mb.ca/healthychild/publications/protocol_cwsn.pdf) the Student Services Administrator coordinates an initial meeting of identified team members and the family. According to the Education and Child and Family Services Protocol for Children and Youth in Care, the legal guardian is responsible to set up an intake meeting with the school team (http://www.gov.mb.ca/healthychild/publications/protocol_youthcare.pdf). The planning meetings are to:

  • identify what is known about the child, what needs to be known, and procedures for gathering information (to avoid duplicating assessments, evaluations and resources);
  • share information with parents/legal guardian about the school;
  • collaborate to develop a transition action plan.

Schools are responsible to implement a transition to school plan in a timely manner, according to the interdepartmental transition protocols (Manitoba Regulation, 155/05).

 

Pre-Kindergarten orientation sessions, reports from Children’s Therapy Initiative clinicians, and information shared by childcare staff are part of the early identification process, as is classroom-based assessment and support.

 

 

Principal Responsibility in Appropriate Education

 

The principal is responsible within the framework of divisional policy, the Public Schools Act, the Education Administration Act, and other relevant legislation, for the organization and supervision of the school, to create optimal learning conditions so that students may find their school to be a safe, attractive, and productive place in which to work, learn, and grow.

 

Individual Education Plan / Behaviour Intervention Plan

 

Principals will:

  • Designate a case manager and ensure that an Individual Education Plan / Behaviour Intervention Plan (IEP/BIP) is developed with the assistance of parents/guardians, student , teachers, and other professionals for any student who is unable to engage in the regular curriculum or has student specific learning needs.
  • Be accountable for the delivery and implementation of educational programming and services for students with exceptional learning needs.
  • Inform parents of student progress at the regularly scheduled reporting periods throughout the year or more frequently if programming changes are deemed appropriate.
  • Ensure that the IEP / BIP:
  • Is prepared and updated by the student support team, which includes:
    • the parents/guardians, who may be accompanied and assisted by a person of their choosing
    • student
    • classroom teachers, and
    • ·other in-school personnel.
  • Includes parental signature(s) to indicate informed parental confirmation of involvement in the IEP process.
  • Takes into account student behavioural and health-care needs (if any).
  • Is consistent with provincial protocols respecting student transition to and from school.
    • Ensure that students who have reached the age of 16 have a transition plan as required by interdepartmental protocol agreements (MR 155/05, provincial transition protocols).
  • Includes information about the student’s current level of performance and achievement relative to identified learning outcomes (MR 155/05).
  • Is updated annually or sooner if required by a change in the behaviour or needs of the student.
  • Is reported on to parents/guardians at least twice a year and/or at least once a semester, coinciding with regular reporting periods (PSA 58.6, MR 155/05, MR 468/88).
  • Ensure that all students with special needs that require transportation accommodations have a Personalized Transportation Plan (PTP). (Policy Guidelines for Transportation of Students with Special Needs, 2004).

 

Discipline / Suspension

 

Schools shall provide reasonable accommodation for students who have exceptional learning needs that affect their behaviour. When disciplining students, the school will consider students’ ability to comply and the supports needed to learn appropriate behaviour (Manitoba Regulation 468/88).

 

The safety of all students is the basis of all disciplinary responses. Schools shall provide a continuum of supports, including positive and preventative approaches and strategies identified and implemented by the school team through the behaviour intervention planning process.

 

  • Principals must inform parents any time a student is sent home for disciplinary reasons
  • Principals must ensure the student’s safety when a student is sent home for disciplinary reasons
  • Any time a student is sent home for disciplinary reasons, the principal must identify a re-entry process that includes timelines, ensuring the student re-enters on the day following suspension. Parents, the student and appropriate school team members should be involved.
  • A Behaviour Intervention Plan must be developed for any student who is sent home for disciplinary reasons more than two times during the school year.

 

When school-based supports and safety plans are insufficient to ensure the safety of students, an alternative location and programming may be a part of the behaviour plan. This may mean a student could go home for a part of a day or may be out of the school for a longer period of time, as part of their educational programming. Aside from continued academic programming outside of the school, educational programming must address the students’ behavioural learning needs.

 

Students with special needs are suspended from attending school in rare circumstances. Suspension decisions should be based on a consideration of the safety and learning supports needed. When a student with special needs is suspended, schools have an increased level of responsibility to:

  • communicate with parents to ensure the student’s safety
  • use the information as part of the planning for the student’s learning
  • collaborate with the entire student support team to address causes of the behaviour and learning needs
  • identify a re-entry process that includes timelines involving the students, parents and appropriate school team members, and ensure re-entry occurs on the day following the suspension
  • ensure that a behaviour intervention plan is written, implemented, and monitored during the suspension(s) and upon re-entry

 

Individual Education Plans

 

School teams may develop student-specific plans where students do not require individualized programming. These plans outline processes for meeting learning outcomes in the regular curriculum. Likewise, many students who are able to access the regular curriculum may require a variety of interventions or support in the areas of health care, remediation, or technological adaptations. Parents should be included in planning, and progress should be monitored, documented and reported to parents.

 

When a school team has identified that a student has exceptional learning needs that require student-specific outcomes that are additions to, are different from, or exceed the curricular outcomes, then an individual education planning process should occur.

 

Manitoba Education requires an individual education plan (IEP) when:

 

  • a student is unable to meet or approximate regular learning outcomes
  • a student receives Special Needs Funding Level II or III
  • a student is determined to be eligible for the English as an Additional Language (E) designation, the Modified (M) course designation, or the Individualized Programming (I) designation in grades 9 to 12.

 

The need for an IEP is determined through a process of observation and informal or specialized assessment in consultation with parents/guardians and the school and Division team.

 

In the IEP, the school team identifies the academic, social, emotional or behavioural outcomes that are required to support student learning in the classroom. Student-specific outcomes differ from the curricular outcomes.

 

In Border Land School Division, school teams use collaborative person-centered planning processes (e.g. PATH & MAPS) and document student-specific planning using:

  • an Adaptation Checklist – developed to document changes to materials, the environment and teaching methods that support the student in learning the regular curriculum
  • a Student Profile – developed to document the student’s strengths, interests, learning needs, and to clarify priority learning goals
  • the Individual Education Plan (IEP) – documents the development and learning of student-specific learning outcomes
  • a Behaviour Intervention Plan (BIP) – developed when behaviour is identified as the priority learning need
  • an Individual Transition Plan (ITP – developed when transition to adulthood is the priority learning need

These are all methods of documenting individual education plans.

 

IEPs and/or BIPs are developed, revised, implemented, monitored, and evaluated at least twice a year and at least once each semester in grades 9 to 12, by the team, including parents/guardians, students, teachers, and other professionals.  The Division will obtain parent/guardian signatures on IEPs to indicate involvement in the IEP process.  In cases where the Division is unable to obtain parent/guardian signatures, reasons for refusal and actions undertaken by the school to resolve concerns will be documented.

 

Students with IEPs or BIPs who have a reduction or alteration in the school day must have it documented in the IEP or BIP.  Students will not be denied educational programming pending the development of an IEP/BIP.

 

Specialized Assessment

 

Teachers are expected to provide instruction based on the curriculum for every student in their classrooms. This must include differentiated instruction and adaptations to assist the students to meet expected learning outcomes. Expected learning outcomes are identified in the regular curriculum and include social/emotional, behavioural, sensory, physical, cognitive/intellectual, communication, academic and health outcomes.

 

Teachers play a key role in identifying the need for further assessment. Classroom based assessment must guide programming decisions for students. They must identify when a student is having difficulty meeting the expected learning outcomes once adaptations and differentiated instruction have been demonstrated to be insufficient.

 

The following steps indicate the sequence of intervention and assessment for students struggling to meet expected learning outcomes at grade level, including on-going communication and collaboration with parents/legal guardians:

 

  • Differentiated instruction for the whole class and possible adaptations for the student documented by the classroom teacher. Adaptations are changes to the teaching process, materials, assignments, or learning products to help a student achieve expected learning outcomes. The Resource Teacher’s role is to support classroom teachers in planning for and providing instruction for diverse students through a collaborative consultation service delivery model.
  • Consultation and collaboration between the classroom teacher, parents/guardians, administrators, resource, guidance, and other in-school support to ensure that parents are informed of the child’s current level of performance and involved in planning supports for learning
  • Further adaptation and accommodation to respond to student’s learning needs; classroom based assessment to monitor the impact of the supports on the student’s learning
  • Possible referral for specialized assessment (i.e. speech and language, psychology, physiotherapy).
  • Implementation of recommendations from specialized assessment, including a team decision about modification or individualized programming.
    • Modifications are changes in the number or content of the learning outcomes a student with a significant cognitive disability is expected to meet in the provincial curriculum, as determined by the student support team.
    • Individualized programming is intended for students whose cognitive disabilities are so significant that they do not benefit from participating in curricula developed or approved by Manitoba Education; it identifies highly individualized learning experiences that are functionally appropriate.
  • On-going formative and summative differentiated assessments of students’ learning related to curricular outcomes and student-specific outcomes.
  • On-going collaboration of the student-support team to use informal, formal and specialized assessment to evaluate performance and plan next steps to support further student learning.

 

Principals will:

 

  • Ensure that a student is assessed as soon as reasonably practicable and referred for a specialized assessment if the in-school team is unable to assess why a student is having difficulty meeting the learning outcomes and is of the opinion that the student cannot meet learning outcomes even with differentiated instruction and adaptations.
  • Ensure that the parent/guardian of the student is informed before the student is referred for a specialized assessment.  No interviewing or testing as part of the specialized assessment may occur without the written informed consent of the parent/guardian.

 

Border Land School Division will:

Ensure that qualified professionals conduct specialized assessments, interpret results, follow principles of fair assessment practices, and provide parents and the school team with programming recommendations.

 

Referrals at this level require informed parental consent for assessment and information sharing on the referral form (see Request for Clinical Services). Informed consent is the parents’ and student’s voluntary consent to participate in assessment, after being fully advised of the benefits and risks. It can be withdrawn at any time. Parents sign a referral form to indicate consent.

 

School teams must collaboratively prioritize referrals for specialized assessments based on needs through a pre-referral consultation with clinicians. These referrals also require the consent of the designated professional in the Student Services Office.

 

Clinicians will collaborate with parents and other service providers to complete specialized assessments when appropriate (Manitoba Regulation 155/05). Prior to specialized assessment, the student support team will gather and share information from parents and students, teacher observation, formal and informal classroom assessment, and assessment information from any other support services.

 

 

Clinicians will provide timelines on specialized assessments, including timelines for follow-up meetings, reporting of results, and written reports. Assessment results will be written and interpreted for parents using language that can be clearly understood.  Clinicians are expected to comply with all professional standards, licensing requirements, and guidelines set by their respective professional organizations.

 

Subsequent to specialized assessments, the student support team will:

 

  • develop programming based on the recommendations of the assessment results (Manitoba Regulation 155/05)
  • develop student specific outcomes in the Individual Education Plan (IEP) based on the recommendations of the assessment results
  • assign support services based on the recommendations of the assessment results
  • prepare the student IEP with the assistance of the parents, students (when appropriate), teachers, and other professionals as directed by the principal. Once a student has been assessed and an IEP has been implemented, regular on-going reviews in subsequent years will be in effect. See Individual Education Plan.
  • Develop and implement a plan for assessing and communicating the student’s learning of student-specific outcomes, using the recommendations of the specialized assessment. The assessment information gathered must inform the next steps in the student’s learning.
  • involve teachers, along with parents/guardians, students (when appropriate), and other professionals in the implementation, monitoring, and evaluation of the IEP.  Parents/guardians may bring an advocate to any of the meetings if they so wish.

 

  • Teachers are required at regularly scheduled reporting periods to inform parents/guardians of student progress for students working towards expected learning outcomes and specific learning outcomes for students as outlined on an IEP.

 

Students will not be denied educational programming pending the completion of an assessment.

 

Dispute Resolution for Parents/Guardians

 

Border Land School Division recognizes that parents/guardians have a critical role in the educational programs for their children.  For this reason the Board has made Divisional policies accessible to parents/guardians and recognizes their rights to make informal and formal appeals with respect to decisions about their children’s educational programming.

 

The School Division will make all reasonable attempts to resolve disputes informally, using dispute resolution processes, such as mediation.

 

Any questions or concerns parents have regarding a student’s educational program shall be addressed to the teacher responsible for the program. If issues cannot be resolved, parents shall contact the principal.

 

When a disagreement cannot be resolved at the school level, the parent/guardian may request the involvement of Divisional staff.

 

The first step within Divisional staff is to contact the Student Services Coordinator, then the Assistant Superintendent, and finally the Superintendent.

 

If the concern still cannot be resolved, the parent/guardian can make a formal appeal of decisions about their children’s educational programming to the School Board, through the Superintendent. Parents have the right to be accompanied by a supporting person.

The Board will review the appeal, make their decision, and advise all parties in writing. The Board will advise parents of their right to request formal dispute resolution through Manitoba Education when efforts to resolve the issues at the school and school division level have failed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Description: Borderline Butterfly - yellow

BLSD Clinical Services Team

120 9th St. N.W.

Altona, MB R0G 0B1

Ph. 204-324-6491

Fax 204-324-1644

Initial

 

Request for Clinical Services

 

taking flight...

 

 

 

 

 


PRE-REFERRAL CONSULT WITH CLINICIAN:  Date: ______________     Staff involved: _____________               

 

REQUEST FOR BLSD Clinician:

School Social Worker School Psychologist Speech & Language Behavior Support Teacher

Student Services Approval by:

Date of approval:

 

 

STUDENT INFORMATION:

Name:

Birth Date: Year: _____ Month: _______ Day: _____

School:

Grade:

MET Number:

 

 

 

 

 

 

 

 

 

Home Room teacher:

Language(s) spoken in the home:

 

Funded: No Yes Level: Category: Until:

Programming: IEP AEP BIP EAL

Psychology information pkg. submitted: No Yes To Pyschologist To Student Services Coordinator

 

CONTACT INFORMATION:

Parent(s):

Legal Guardian: Phone:

Foster Parent:

Home Address:

Town:

Postal Code:

Phone Numbers - Home: Work: Cell:

 

REASON FOR REFERRAL

Referral Concerns Checklist - place a checkmark next to each item of concern.

 

Academic

Cognitive

Behavioural

Speech & Language

  • €Decoding words
  • €Reading comprehension
  • €Math calculation
  • €Spelling
  • €Written expression
  • €Concentration/attention skills
  • €Comprehension
  • €Problem solving
  • €Memory
  • €Organizational skills
  • €Disrespectful/rude
  • €Disruptive/attention-seeking
  • €Compliance
  • €Aggression
  • €Attendance/punctuality
  • €Lies/steals/cheats
  • €Self-harm/suicidal
  • €Drug/alcohol use
  • €Articulation
  • €Language
  • €Fluency
  • €Non-verbal
  • €Voice

Temperament

Social/Self-Care

Perceptual/Motor

  • €Anxious/fearful
  • €Mood
  • €Frustration tolerance
  • €Flexibility/Rigidity
  • €Intensity
  • €Social skills
  • €Impulse control
  • €Maturity
  • €Self-esteem
  • €Self-care skills
  • €Fine motor
  • €Gross motor

Other

  • €

 

Highest priority concerns are:                                                                                                                                                                                                                                                                                                                       

 

Remedial actions already attempted (include test scores):                                                                                                                                                                                                                                                                                                                                                                                                                                                              

 

Text Box: Page 1 of 2Desired student outcome(s):                                                                                                                                                                                                                                                                                                                         


 

ASSESSMENTS AND SPECIALIZED SERVICES

Vision Screening/Assessment:            Date: ________________      Results: _____________________________

Hearing Screening/Assessment:         Date: ________________      Results: _____________________________

 

Professionals currently involved.  Check boxes that apply and explain below.

 

School Social Worker School Psychologist Speech & Language Behaviour Support Teacher

 

  • €OT/PT
  • €Deaf/Blind Consultant
  • €Mental Health Services
  • €CFS
  • €Family Services & Housing
  • €Counsellor
  • €Family Doctor
  • €Medical Specialist
  • €Other

__________________________________________________________________________________________

__________________________________________________________________________________________

 

Professionals previously involved.  Indicate date D/M/Y.

School Social Worker School Psychologist Speech & Language Behaviour Support Teacher

 

  • €OT/PT
  • €Deaf/Blind Consultant
  • €Mental Health Services
  • €CFS
  • €Family Services & Housing
  • €Counsellor
  • €Family Doctor
  • €Medical Specialist
  • €Other

                                                                                                                                                                                   

__________________________________________________________________________________________

 

MEDICAL INFORMATION:  Check boxes that apply and explain below.

Allergies Middle ear infection Syndromes High Fever Surgeries Medications Other

 

__________________________________________________________________________________________

__________________________________________________________________________________________

 

FAMILY INFORMATION:  Family History of speech or learning disabilities:         No         Yes – explain:

__________________________________________________________________________________________

Has this student experienced any significant stressful events over the past year?        No         Yes – explain:

__________________________________________________________________________________________

__________________________________________________________________________________________

Other pertinent family information (loss, separation or other recent changes):  __________________________

__________________________________________________________________________________________

Siblings/Ages:  ______________________________________________________________________________

 

The Clinical Services Team offers specialized help to students and their families. The services are provided by a team that is comprised of Social Workers, Psychologists, Speech/Language Pathologists and Behaviour Support Teachers. One or more of the above clinicians may become involved in assisting with specific needs. Information will be shared with you. We work closely with school personnel and provide them with verbal and written information to assist in programming and in understanding the student’s needs. All identifying information will be kept confidential. If other professional services are needed, you will be contacted.

 

Parent/Guardian: _____________________________________     Date: _______________________________

Classroom Teacher: ___________________________________     Date: _______________________________

Resource/Guidance Teacher: ____________________________    Date: _______________________________

School Principal: ______________________________________    Date: _______________________________

This personal information is being collected under authority of Border Land School Division and will be used for educational purposes.  It is protected by the Protection of Privacy Provisions of the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection, contact the Border Land School Division Access and Privacy Coordinator at 204-324-6491.                                                                          Page 2 of 2


BLSD Clinical Services Team

120 9th St. N.W.

Altona, MB R0G 0B1

Ph. 204-324-6491

Fax 204-324-1644

Description: Borderline Butterfly - yellowAdditional Request

 

for Clinical Services

                                                                                                                              Attach a copy of the Initial Request for Clinical Services

taking flight...

 

 

 

 

 

 

 


PRE-REFERRAL CONSULT WITH CLINICIAN:  Date: ______________     Staff involved: _____________               

 

REQUEST FOR BLSD Clinician:

School Social Worker School Psychologist Speech & Language Behavior Support Teacher

Student Services Approval by:

Date of approval:

 

 

STUDENT INFORMATION:

Name:

Birth Date: Year: _____ Month: _______ Day: _____

School:

Grade:

MET Number:

 

 

 

 

 

 

 

 

 

Home Room teacher:

 

 

Funded: No Yes Level: Category: Until:

Programming: IEP AEP BIP EAL

Psychology information pkg. submitted: No Yes To Pyschologist To Student Services Coordinator

 

CHANGES IN CONTACT INFORMATION:

Parent(s):

Legal Guardian: Phone:

Foster Parent:

Home Address:

Town:

Postal Code:

Phone Numbers - Home: Work: Cell:

 

BLSD CLINICIAN(S) CURRENTLY INVOLVED:

School Social Worker School Psychologist Speech & Language Behavior Support Teacher

 

REASON FOR REFERRAL TO ANOTHER DISCIPLINE:  Check any concerns that have arisen since original referral.

Academic

Cognitive

Behavioral

Speech & Language

  • €Decoding words
  • €Reading comprehension
  • €Math calculation
  • €Spelling
  • €Written expression
  • €Concentration/attention skills
  • €Comprehension
  • €Problem solving
  • €Memory
  • €Organizational skills
  • €Disrespectful/rude
  • €Disruptive/attention-seeking
  • €Compliance
  • €Aggression
  • €Attendance/punctuality
  • €Lies/steals/cheats
  • €Self-harm/suicidal
  • €Drug/alcohol use
  • €Articulation
  • €Language
  • €Fluency
  • €Non-verbal
  • €Voice

Temperament

Social/Self-Care

Perceptual/Motor

  • €Anxious/fearful
  • €Mood
  • €Frustration tolerance
  • €Flexibility/Rigidity
  • €Intensity
  • €Social skills
  • €Impulse control
  • €Maturity
  • €Self-esteem
  • €Poor self-care skills
  • €Fine motor
  • €Gross motor

Other

  • €

 

 

Changes in medication(s), diagnoses, pertinent family information:                                                                                                                                                                                                                                                           

­Verbal consent given by parent/guardian on:                           Obtained by:                                                            

Resource/Guidance Teacher: ____________________________                 Date:                                                                                                                                                          

 

          Border Land School Division

BORDER LAND SCHOOL DIVISION

120 9th Street NW, Altona, MB,  ROG OB1       Phone: (204) 324-6491   Fax: (204) 324-1664

Transportation Co-ordinator’s office:  (204) 427-2091 or Toll Free:  1-866-427-2091

 

PERSONAL TRANSPORTATION PLAN

 

STUDENT INFORMATION:

Bus Driver: Bus Number:

Name of Student: Other:

School to be Attended:

Frequency of Service:

Father’s Name: Phone :

Phone:

Mother’s Name: Phone:

Phone:

Emergency Contact Person: Phone:

 

 

EMERGENCY HEALTH CARE INFORMATION:

 

URIS Health Care Plan: Yes No

 

Allergies: Yes: No: Type:

Medication: Yes: No: Type:

Handicapping Condition/s:

 

Treatment of Handicapping Condition/s:

 

 

Doctor: Contact Phone #:

 

Hospital: Contact Phone #:

 

 

SPECIAL NEEDS OF STUDENT THAT SHOULD BE KNOWN BY BUS DRIVER

Age: Weight: Height:

 

Ambulatory

 

Non-Verbal

 

Confined to wheelchair

 

Non-English/French speaking

 

Can be transferred to seat

 

Severe speech problems

 

Hearing Impaired

 

Has seizures

 

Visually Impaired

 

Hyperactive

 

Wears leg braces

 

Self-Abusive

 

Walks with crutches

 

Other:

Special Supports:

Wheelchair Measurements:

Loading Time at Home:                                                Unloading Time at School:

Loading Time at School:                                               Unloading Time at Home:

 

 

 

 

SIGNATURES:

 

______________________________________________         ____________________________________

                                Parent/Guardian                                                                      Date

_____________________________________________           ____________________________________

                                Transportation Co-ordinator                                                   Date