SEN Transport Application – Ages 0-18

To qualify for any travel assistance, an application must be submitted for each individual applicant. Once a placement at an education facility has been secured for any age, an application will need to be assessed by the specialist travel team.

We understand that any information shared is confidential and we will only share this information with those who need to know. This form asks for information which in our experience can have an impact on an individual's journey.

For further information please see Education travel assistance - SEN pupils.

Data Protection

Shropshire Council will use the information you provide for the purpose of processing your child's transport entitlement request. It will be retained for a maximum of 6 years, from the receipt of this application.

Consent for storing submitted data (you must tick yes to complete the form) * Yes, I give permission to store and process my data
No, I don't consent to storing and processing my data

Parent/Guardian/Carer details

Title: *

Relationship with student: *

First Name: *

Last Name: *

Email: *

Home Telephone:

Mobile Telephone: *

Work Telephone:

Enter Student Address or Postcode and choose the correct entry from the list:*

Address Line 1: *

Address Line 2:

Town: *

Postcode: *

Have you moved in to this address within the last 3 years:
Yes No

Pupil Details

Title: *

First Name: *

Last Name: *

Gender: * Female Male N/A

Date of birth (dd/month/yyyy):*

School / College details

School or College to be attended:*

Other School: *

Campus Name:

Course title:

Subjects:

Transport start date (dd/month/yyyy):*

Student age range: * Nursery Age – Under 5 years Statutory - age 5 to 15 years Post 16 - age 16 to 18 years

Emergency contacts

Please provide details of two contacts that you would like us to call in the event of an emergency.

Emergency Contact 1 Name:*

Emergency Contact 1 Relationship to Applicant:*

Emergency Contact 1 Address:*

Emergency Contact 1 Town:*

Emergency Contact 1 County:*

Emergency Contact 1 Postcode:*

Emergency Contact 1 Home Telephone:

Emergency Contact 1 Work Telephone:

Emergency Contact 1 Mobile:*

Emergency Contact 2 Name:

Emergency Contact 2 Relationship to Applicant:

Emergency Contact 2 Address:

Emergency Contact 2 Town:

Emergency Contact 2 County:

Emergency Contact 2 Postcode:

Emergency Contact 2 Home Telephone:

Emergency Contact 2 Work Telephone:

Emergency Contact 2 Mobile:

Changes to transport

Sometimes we will need to make changes to your transport due to retendering, review or circumstances beyond our control. Please tell us how we can help manage and support change for the applicant:

Is there anything more we need to know? Please use this space for any information that you feel will help the driver and ourselves for any future travel planning to ensure the journey is as safe as possible:

Declaration

I confirm that the information I have provided is correct to the best of my knowledge. I understand that if any information I have supplied is found to be intentionally false in order to gain travel assistance, that travel assistance may be revoked.

I have read and confirm the above declaration *

Shropshire Council