Hartford Public Schools Transportation Department

Special Needs Transportation

REQUEST FORM SPECIAL NEEDS TRANSPORTATION SY 09-10

960 Main Street

Hartford, CT 06103

Transportation Hot Line (860)695-8547

*Student ID: *VENDOR (Select One)
DATTCO SY 09-10
LOGISTICARE SY 09-10
*Date of Request *What is the Transportation Start Date? *What is the Transporation End Date? *Type of Transportation Request (click applicable fields) *Bus Monitor Required by IEP:
Yes No *Bus Monitor Start Date: *Bus Monitor End Date: *Equipment Requested:
Wheelchair Vehicle
Car Seat
Vest/Harness
None Required
*Select Kind of Request Type of Disability *Student Last Name *Student First Name *Date of Birth *Gender *Grade (Select One) *Current Street Address: *Pick up Address *Drop Off Address Old Street Address *Current City, State, Zip Old City, State, Zip (Suburban Magnet Only) Sending Town (Suburban Magnet Only) Enter Sending School (Hartford Schools Only) *Enter Receiving School in Hartford *Enter Receiving School *Parents/Guardian's Names: *Home Phone Number (Must Provide a number) Work Phone Number: Cell Phone Number Submitted by Sepcial Needs Coordinator: *Name of Person Sending Request *Enter your Email Address: *Phone Number School Official Comments:

All request will be reviewed and acted upon within 3 school days from the date received. If you have any questions, please call the Transportaion Hot Line at 695-8547.

Thank You,

Transportation Department.

Hartford Public Schools Transportation Department

School Year 2009-2010

Special Needs Transportation