EEADA Form A - Adopted 8/14/07
APPLICATION FOR EARLY CHILDHOOD SPECIAL EDUCATION
TRANSPORTATION REQUEST OR MILEAGE REIMBURSEMENT
Special Programs Director
Jefferson County School District 509-J
445 SE Buff St
Madras OR 97741
Phone 541-475-2804 - Fax 541-475-2827
APPLICATION FOR EARLY CHILDHOOD SPECIAL EDUCATION
TRANSPORTATION REQUEST OR MILEAGE REIMBURSEMENT
This form is to be completed by the Early Intervention/Early Childhood Special Education Coordinator for those students to be considered for approval for transportation services or for mileage reimbursement from the Jefferson County School District 509-J. The following procedure must be followed:
A. The Warm Springs EI/ECSE Coordinator notifies the Special Programs Director of the need for transportation. This request should be sent to the following email address: bgarland@509j.net.
B. Complete this form and return it to the Special Programs Director at the above address.
C. This form must be re-submitted to the Special Programs Director prior to the beginning of each school year for each child for whom transportation is being requested or for each child for whom mileage reimbursement for parent transport is being requested.
D. Attach the Individual Family Service Plan cover sheet and Parent Signature page to this application.
E. If this application is approved, submit a mileage reimbursement form to the Support Services office each month that special transportation services are provided.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Early Intervention-Early Childhood Coordinator please complete and sign:
Child’s Name____________________________________ DOB ____________________________________
Parent/Guardian Name___________________________________ Daytime Phone _______________________
Mailing Address___________________________________________ Cell Phone _________________________
Street Address____________________________________________ Email _____________________________
Date certified as eligible for Early Intervention/Early Childhood Special Education services __________________
Is the child eligible for transportation services provided by the Warm Springs Early Childhood Education program? Yes / No
Number of miles from street address to Warm Springs Early Childhood Education program (one way) ____________________________
Number of days per week transportation is required by the Individual Family Service Plan for the child to access his/her special education services______. Please specify days by circling: M T W TH F
Early Intervention – Early Childhood Special Education Coordinator ____________________________________
Please Note: Mileage reimbursement will not be made to parents for students who have missed the bus.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Early Childhood Program / Jefferson County School District 509-J Use:
Jefferson County School District 509-J DOES / DOES NOT provide regular bus service to the above address.
Jefferson County School District 509-J DOES/ DOES NOT provide special education bus service to the above address.
Jefferson County School District 509-J APPROVES/DOES NOT APPROVE this application for mileage reimbursement.
Signatures for Authorization:
__________________________________________________
Transportation Dept. Supervisor
_______________________________________________________
Special Programs Director
"