If you need a copy of this form in large print or Braille, please contact (option 2)

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1 Application for support with home to college travel arrangements for young people who have recognised learning difficulties and disabilities 2015 to 2016 for full-time students who are aged 16 to 24, live in Leeds and attend a state-funded college of further education Issued by: The SEN Transport Assessment Team Passenger Transport Civic Enterprise Leeds Westland Road LEEDS LS11 5SB If you need a copy of this form in large print or Braille, please contact (option 2)

2 Guidance notes Who is the application form intended for? You may use this application form if: you are over the age of 16, but not yet 25; you have a recognised learning difficulty and/ or a disability that is known to impede travel to and from college; your permanent home address is in the Leeds district of West Yorkshire; you attend college on a full-time basis - this means that the course on which you have enrolled must involve at least 12 hours of guided learning at college each week of the college s academic year; you are enrolled at the nearest government-funded college of further education that offers the course you want to do; and you would have to walk at least three miles to get to that college. We will use the information you give us to check whether you are entitled to support. It is important to note that the children s transport policy is continually under review. Previous consultation around Post-16 SEND transport assistance was paused in the spring of It remains the intention to review the discretionary support made available for Post-16 SEND students. Proposals for a renewed consultation exercise will be considered by the Council s Executive Board on 16th December Further information will be made available in the near future. You are strongly advised to check these pages for further details as they become available. More information is available on our website at: Alternatively you can for more information: childrenstransport@leeds.gov.uk We will also work closely with schools, SILCs and colleges to communicate more information about how you can participate in our consultation. What sort of support could I get? We will assess what would best meet your needs and, if we agree to help you, we will provide the least restrictive form of support that we can. It could be one or more of the following: a Zero Fare School Pass, which is a smart card that allows one journey to college and one journey home between 6am and 10pm without having to pay the appropriate fare it is accepted for travel on buses and trains operating within the county of West Yorkshire and is valid on more than one service if no direct service is available and you need to change from one bus service to another (or from bus to train and vice versa), but it is not valid if you break your journey unnecessarily and try to re-board without paying; travel training to enable you work towards travelling independently on public transport; a travel buddy who could walk with you or travel to and from college with you on public transport for a short period of time, until you are able to travel independently; a mileage allowance, fixed payment or travel allowance if one of your parents or carers wants to use their own vehicle to take you to and from college; a taxi or minibus to transport you from your permanent home address to college and back - if we offer to provide you with a taxi or a minibus, you may have to share with other students whose timetables are different to your own and this could mean you having to stay in college for up to two hours of private study or recreational activity. a passenger assistant to travel with you in a taxi or minibus.

3 I cannot use public transport so I am asking for a taxi. If I do get one, will it take me to college for taster sessions, induction days or to other locations? No. We do not provide transport for taster days, induction days, enrichment activities, work placements or work experience. For these, you will need to make other arrangements. Speak to your tutor for more information. I have behaviour difficulties. What else do I need to know? We have a duty to ensure the health, safety and well-being of students and the people who are employed to help them in any way. If your behaviour is likely to place yourself or other people in danger, then should it become necessary we reserve the right to withdraw the provision of transport, pending review and reassessment of your travel needs. If you are awarded a Zero Fare School Pass and you breach the Code of conduct given in these guidance notes or Conditions of use listed in the carrier letter that accompanies the pass, the bus or train operator may withdraw the pass. You would have to write to Metro to explain what happened. How do I apply for support? You must: read the guidance notes carefully; fill in all parts of the application form that are relevant to you; ask your doctor or other qualified medical professional to complete Part 6 for you; when your timetable is finalised, give the form to your tutor or other college representative so he or she can fill in Part 7; read and sign the declaration in Part 8; put your application in a suitable envelope; include any extra information you want us to look at; and send your application to the address shown on the form - if you post your application to us, we advise you to get a Certificate of Posting from the Post Office and check that you have used the correct postage because underpayment will result in significant delays. If you are applying for a Zero Fare School Pass, you should also: attach a passport-approved photograph measuring 35mm x 45mm write your name, date of birth and the name of your college on the back. We will return the form to you if: any part of the application is missing; you haven t given us all the information we need; or the photograph you send us isn t suitable. How will I know if I qualify for support? We will write to you at your permanent home address. You must allow up to 15 working days for us to process your application from the date we receive your fully-completed form. Please bear in mind that if we agree that you need a taxi or minibus, it can take several weeks to put the necessary arrangements in place. In these circumstances, the local authority may then make a retrospective, discretionary award of no more than 25 per week for journeys between home and college that you, your parent or carer organise from the date we receive your fully-completed application form to the date on which local authority-agreed arrangements commence. We advise you to apply as soon as your timetable is finalised. What if I move house or changes are made to my course? You must phone the SEN Transport Assessment Team on (option 2) at once. Existing arrangements may be terminated. If you still want support getting to and from college, you must fill in a new application form that includes up-to-date information so we can re-assess your needs.

4 What if I apply for support, but I don t qualify? We will send you a letter explaining exactly why. Where appropriate, we will also return your photograph and supporting documents. What if I need to make other journeys? If you need to find out which buses serve the area in which you live, call Metroline on Bus and train times in West Yorkshire can also be found on Metro s website at Full-time students who are permanently resident in West Yorkshire and aged 16 to 18 are permitted to travel at half-fare on buses and trains within West Yorkshire on production of a Scholar s PhotoCard. Application forms and further details should be available from your college. If you are disabled or blind and want to apply for an English National Concessionary Pass, ring Contact Leeds on or write to Contact Leeds, P.O. Box 657, Leeds LS1 9BS

5 Code of conduct for college students in receipt of Zero Fare School Passes Waiting for the bus or train Students must: queue sensibly, away from the road or the edge of the platform; and get on the bus or train calmly, without pushing. On the bus or train Any student in receipt of a Zero Fare School Pass must: show their valid Zero Fare School Pass to the driver or conductor; hold their pass against the electronic smart card reader if there is one on the service; find a seat and stay seated throughout the journey - if there are no seats, they must stand and hold on to a handrail; show respect for other passengers; and behave sensibly throughout their journey. Students must not: attempt to use the Zero Fare School Pass other than to or from college to avoid paying the appropriate fare; do anything to distract the bus driver unless in an emergency; cause any damage to property; interfere with CCTV equipment or any other safety equipment; take photos without prior consent of the person(s) involved; or use abusive language or threatening behaviour. If a student breaches any condition set out above, they could: have their Zero Fare School Pass withdrawn - any request for its return would need to be made, in writing, to Metro; be banned from the bus or train; be prosecuted by the Police; and be required to pay for any damage they have caused.

6 Application for support with travelling arrangements to and from a college of further education for 2015 to 2016 for a young person with a recognised learning difficulty or disability Data Protection - Please be aware that the information you supply on this application will be used to assess eligibility for assistance, recorded on computer and, if successful, may be shared with Leeds City Council s Passenger Transport section; Leeds Alternative Travel (who help deliver independent travel training); Metro; and the Zero Fare School Pass supplier. All data will be held strictly in accordance with the Data Protection Act We advise you to read guidance notes before you fill in this form. Please use black or blue ink and write in CAPITAL LETTERS. If you are applying for a taxi or minibus, please complete all eight parts of this form. If not, please ignore parts 2, 3 and 4 you may leave them blank. Part 1 - Your details First name: Last name: Date of birth: / / Age: Male Female Are you fostered or in public care? No Yes If yes, to which local authority? Permanent home address: Postcode: Have you moved house since you left school? Your contact telephone numbers and address: Home: Mobile: Name of your college: Full address of the campus you attend: Postcode: What course are you doing between September 2015 and July 2016? Please tell us about your learning difficulty or disability:

7 Were you at school or college between September 2014 and July 2015? Yes No If yes, which one? What were you studying? How did you travel? Do you have an Education Health and Care Plan? If yes, who is your Casework Officer? Do you have a Metro concessionary travel permit? Don t know Are you capable of travelling independently on public transport: Now, without a passenger assistant? Now, with a passenger assistant? In future, after appropriate travel training? What sort of support do you think you need: A Zero Fare School Pass? Independent travel training? A travel buddy to walk with you? A travel buddy on public transport? A mileage allowance? A travel allowance? A taxi or minibus? A passenger assistant on a taxi or minibus? If you are applying for a Zero Fare School Pass, please attach one passport-approved (35mm x 45mm) photograph of yourself here. On the back, write your: name; college; and date of birth. Please tell us why:

8 Section 2 Your mobility Are you able to: walk unaided? climb steps? walk unaided but with some difficulty? walk with assistance? Do you: use a mobility aid to walk? need help to get into, or out of, a vehicle? have difficulty accessing a car? have difficulty accessing a people carrier? have difficulty accessing a minibus? If you have answered yes to any question relating to mobility, please give further details: Would you need to take any of the following mobility aids on transport: crutches (pair)/ quad crutch? posture walker? frame? If yes, is it foldable? Wheelchairs Do you use a wheelchair? If yes, is it: manual? Please state the make and model: electric? Please state the make and model: a scooter? Please state the make and model: Do you have to travel in your wheelchair? If yes, has the make and model been Transport Crash Tested? Don t know Has the wheelchair been modified in any way since then? Don t know If you are a wheelchair user who can transfer to a seat in a car or minibus, can you do this: on your own? with help? Can your wheelchair or scooter be folded? Do you need to take it to and from college with you?

9 Seatbelts and harnesses All young people must wear a seatbelt or harness when they travel to and from college. Do you need to wear a harness (for example a breastplate harness) when you travel? Please give details of any other seating requirements: _ Part 3 Your health needs and medical conditions Do you have any health needs that we should be aware of? Please tick all that apply: Allergies (plasters or other) Autistic Spectrum Disorder Balance and co-ordination difficulties Breathing problems Breathing problems requiring suction Continence issues Diabetes not yet controlled Emotional or behavioural issues Hearing difficulties Hearing impairment Moderate learning difficulty Multi-sensory impairment Physical disability Profound and multiple learning difficulties Profound challenging behaviour Speech, language or communication difficulty Visual impairment Other, not listed above If you have ticked Yes to any of the above, please give additional information in the space below. Continue on a separate page if necessary:

10 Do you have epileptic seizures? Yes No If yes, please indicate the type of seizure: Tonic-clonic Absence Both If there are any visible warning signs prior to a seizure, please tell us what we should look for: Generally, how long do seizures last? What could transport staff do to assist you if you had a seizure? At what point would transport staff need to alert emergency services? If your health or medical conditions will be an issue when travelling, please give details below. Include any actions that should be taken and what, if any, warning signs drivers and passenger assistants should be aware of: Medication Please note that drivers and passenger assistants are unable to administer medicines or offer medical treatment. Do you need to carry any medicines (for example an Epipen or inhaler) with you between home and college? If so, please give details: Do you have a medical condition that means you might need medical treatment whilst you are travelling? No Yes If so, you must give full details on a separate sheet.

11 Part 4 Contact details and emergency procedures Details of your parent, carer or legal guardian Title: First name: Last name: Relationship to you: Home address: Postcode: Contact telephone numbers and address: Home: Mobile: Work: Latch-key agreements We know that some young people have their own house key and let themselves in when they get home. Would you be able to let yourself in once a taxi or minibus had dropped you off? If we award you a taxi or minibus and you cannot let yourself in, there would need to be someone at home to meet you when you get home. If, in the event of a genuine emergency due to unforeseen and unavoidable circumstances, there would be no one there, an arrangement can be put in place for you to be taken to a pre-arranged alternative address. If you would like to set up such an arrangement, please give details of a person who has agreed to take care of you until your parent or carer can collect you. Details of a second person who can be contacted in an emergency Title: First name: Last name: Relationship to student: Home address: Postcode: Contact telephone numbers and address: Home: Mobile: Work: We will only take you to this alternative address if this is requested either by yourself, or by one of the persons named above. In order to ensure your safety, we need a password that a transport officer will ask you or the emergency contact to confirm over the phone. You must share this password with the person you specify as the emergency contact, in case they ever need to use it. Your password:

12 In case of a medical emergency: In an emergency situation, the driver or passenger assistant would call 999 or divert to the nearest appropriate medical facility. Please confirm that you accept this course of action would be appropriate for your medical needs in the event of an emergency: Yes No If you have ticked No, please give details below: Part 5 Extra information Is there any other information that you feel we need to be aware of when we assess this application? You may continue on a separate sheet if you wish.

13 Part 6 To be completed by your doctor or other qualified medical professional Please give brief details of this student s learning difficulty and/or disability. How might their learning difficulty and/or disability affect their ability to get to and from college? In your opinion, what sort of support would best suit their travel needs? Could he or she travel without the direct supervision of an adult (other than a driver)? Yes No If so, please explain why: I confirm that the information given in Part 6 of this application is correct and complete. Signed: Date of signature: Please print your name: Practice stamp (if applicable): Relationship to student: Contact telephone number:

14 Part 7 - To be completed by a college representative The support offered by the local authority would only cover journeys between the student s permanent home address and the college they attend on a given day to pursue a recognised course of further education. The type of support provided is solely at the discretion of Leeds City Council. What course is the student doing? What (if any) qualification will it lead to by July 2016? Start date of this course: / / End date of this course: / / Please give details of the student s timetable commitments once these are finalised. If taxi provision is sanctioned and changes are made to the details you confirm below, the student or their representative must contact the SEN Transport Assessment Team on (option 2) immediately to cancel existing arrangements. They must then submit a new application that includes up-to-date information. Taxis are not provided for taster days, induction sessions or to any other location. If a student is required to sit an external exam, for example an A Level or GCSE, you must let us have their exam timetable at least one month before the date of the first exam. Day Location Start time Finish time Monday Tuesday Wednesday Thursday Friday Total number of contact hours (excluding lunch breaks) each week: Reasons for supporting the student s request: I confirm that this student has enrolled on the above-named course and that the information given in Part 7 of this application is correct and complete. I understand that if this student is awarded a taxi and the timetable given above is subsequently altered, all existing arrangements are terminated and the student will need to submit a new application. Signed: Date of signature: Please print your name: College stamp: Position: Contact telephone number:

15 Part 8 - Student declaration I declare that: I have read and understood the guidance notes and Code of conduct; to the best of my knowledge, the information given on this form is correct and complete; I have enclosed signed information about my recognised learning difficulty or disability from my doctor or other qualified medical practitioner in Part 6; a college representative has completed Part 7 of this form; I have enclosed all the extra information I want you to look at; I understand that if my application is successful, I must contact the SEN Transport Assessment Officer immediately if my timetable changes, if I move house, or if I leave college; and I also understand that if my behaviour is likely to place myself or other people in danger, the provision of transport could be withdrawn pending review and reassessment of my travel needs. I am not applying for a Zero Fare School Pass. I am applying for a Zero Fare School Pass, so: I have attached a passport-approved photograph for use on the pass and have written my name, date of birth and college on the back; if my application is successful, I will return the pass to the address given below if I move house or leave college; and I understand that the Zero Fare School Pass may be withdrawn if I breach the Code of conduct or the Conditions of use issued with the pass. Signed: Date: Signature of parent or legal guardian (required if you are under 18 or you cannot fill in the form yourself) Signed: Date: Please print your name: Relationship to student: When the application form is fully completed, put it in an envelope and return it to: The SEN Transport Assessment Team Passenger Transport Civic Enterprise Leeds Westland Road LEEDS LS11 5SB Please check that you ve: kept the guidance notes in a safe place; filled the form in properly; enclosed all the extra information you want us to look at; attached a passport-approved photograph if you are applying for a Zero Fare School Pass; and used the correct postage.

16 For office use only Letter Scan Upload Filed Application returned for completion on: / / Eligibility checked on: / / by: by: Student reference number: Nearest government-funded college? Appropriate medical information? College timetable? Signed declaration? Walking distance between home and college: miles Notes: Approved Award determined on: / / by: Confirmation letter sent on: / / By: Award of Zero Fare School Pass? Code: Expiry date: Request sent to Metro on: / / Pass to go to: College Co-ordinator Processed by: Independent travel training? Travel buddy? Co-ordinator: Other provision? Travel allowance: Mileage allowance: Taxi or minibus: Passenger assistant: Parental contribution: Request to Passenger Transport on: / / Cost Code: Start date: / / End date: / / By: Refused Refusal letter sent on: / / by: Reasons for failure: Review request received on: / / Passed to: Application reviewed on: / / Response: