Special Educational Needs Questionnaire

Your Child's Details

Child's Full Name:  

Child's Date of Birth:  

Address:  

Postcode:  

Your Details

Your Title: (eg Mr, Mrs, Miss)  

Your Name:  

Your Home Telephone Number:  

Your Mobile Number:  

Your Email Address: (*Required field)  

Please give us contact telephone numbers for use in emergencies.

Friend/Carer/Spouse Full Name:  

Friend/Carer/Spouse Mobile Number:  

Relationship to Child:  

Please tell us the name and address of a friend, neighbour or relative where your child can be taken. This will be used in emergencies only and must be within 1 mile of your usual address

Contact Name:  

Contact Address:  

Contact Postcode:  

Home Telephone Number:  

Mobile Telephone Number:  

Your Child's Education

If yes, please tell us the name of your child's current School or Nursery:  

If other please specify:  

If your child will attend a new School or Nursery, please give us the name and address of the new School or Nursery

Name of New School or Nursery:  

Address of New School or Nursery:  

Date your child will start this New School or Nursery if known:  

Your Child's Special Needs

If other special needs, please specify:  

If other mobility assistance, please specify:  

If your child uses a wheelchair or buggy, please tell us the Make and Model:  

Please note that if your child uses a wheelchair or buggy, you must attach confirmation from your issuing wheelchair service that the wheelchair or buggy has been crash-tested for use on transport and provide information about which restraints must be used to secure the wheelchair/buggy in place on transport. Please attach both items before submitting this form at the bottom of the page. *

If you have selected other, please can you give us more information about your child’s other condition here:  

If your child requires regular medication, please tell us the medication(s) and the dosage taken:  

If any, what medication or dosage would need to be given to your child in the case of an emergency?  

Members of transport staff are not allowed to carry or administer medication on board a vehicle. If an emergency were to occur while a child were on board transport, the procedure would be for the escort to call 999 and ask for a paramedic crew to attend the scene. It will be for parents to decide whether they would like their child to travel on regular transport under these circumstances if there is a risk that their child may need medication in an emergency.

Please tell us your child's current height and weight so that we are able to assess any special seating requirements

Childs Height (*Required field)  

Childs Weight (*Required field)  

Your Child's Travel Needs

If your child cannot walk on safe routes, please give further details:  

If your child cannot use public transport, please give further details:  

In some cases (where there are not existing transport arrangements in place to this school), The Royal Borough of Kingston may offer parents, or a nominated relative or friend, a financial reimbursement if you are able to take your own child to and from their school or nursery placement. Please let us know here if you are interested in considering this option, and we will make contact with you via your email address to provide you further information.

I am interested in pursuing financial reimbursement as outlined above: (*Required field)  

If you are unable to transport your child to school, please give further details:  

If you are not able to travel with them, please give further details:  

If yes please give us the make and type of any special seating:  

Parent/Carer Declaration

I understand that you will use this information as part of the transport assessment process. I also give my authorisation for medical informaiton about my child to be disclosed to the Local Authority and any transport company which may be employed to provide transport for my child. As far as I know, all the information I have given is correct and I understand that I must tell you if any of my circumstances change.(We will check the information on this form and any incorrect or incomplete may delay your application)

* If your child uses a wheelchair or buggy, please enclose confirmation from your wheelchair service that the wheelchair or buggy is crash-tested for use on transport and provide information about which restraints must be used to secure the wheelchair/buggy in place on transport:     

** Please note that if you wish to send multiple documents, you will need to compress (Zip) them before uploading them (see below for more information)