Northamptonshire County Council Letterhead Template

POST 16 EDUCATION TRAVEL SCHEME APPLICATION FORM FOR THOSE WITH AN EDUCATION, HEALTH AND CARE PLAN (EHCP)

Academic year of application: / .

Please note that applications are for one academic year only. Any subsequent years will need a further application being submitted.

Subject to eligibility, GUARANTEED Seats are only available if completed forms are received by the last working day in May.

Please note that if your application is received after the deadline of the end of May, then there is no guarantee that a seat will be available for your child from the beginning of the new academic year. Furthermore, as this is the busiest period, any applications that are received in August, September or October may not be processed until the October half term. You may have to arrange and pay for your own travel arrangements until the late application can be processed and transport arranged if eligible. No re-imbursements of these costs will be made.

STUDENT DETAILS Student Surname Date of Birth ____/____/____

Student Forename(s) Tel. No.

Address

Post Code

Email Address

School/Establishment

Campus Address & Post Code Please note that we are only able to provide transport to one educational location as indicated by the educational establishment and to the nearest suitable educational establishment as indicated within section I of your EHCP. Please provide a copy of this with your application.

Course details ( Title and length of Course in years) (Please be as specific as possible)

Previous School (If applicable)…………………………………………………………………………………………………..

Which days per week do you expect to attend, if known ( please circle) Mon Tues Weds Thur Friday Please note that transport is provided at the general start and finish of the academic day as inidicated by the educational establishment

Are you a wheelchair user….YES / NO If Yes please supply wheelchair make & model………………………………. .……………..Electric …………….Yes /No Please note that if you need to travel in a wheelchair you will need to check with the manufacturer that your particular model has been crash tested. If your wheelchair has not been crash tested we will be unable to transport you in this.

1 Student height………………………….. ……………………………………Student weight…………………………………….

Student SEN details:- ……………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………

Emergency contact details: Name……………………………………..Phone number………………………………………..

Address………………………………………………………………………………………………………………………………

DETAILS OF PERSON PAYING FOR THE TRANSPORT

Title Mr/Mrs/Miss/Ms Forename(s) Surname

Address Town

County Post Code

Tel. No. Mobile No.

Email Address

Signature Date

HAVE YOU PREVIOUSLY PURCHASED TRANSPORT FROM NORTHAMPTONSHIRE COUNTY COUNCIL?

YES CUSTOMER NUMBER ______NO (This is located on any previous invoice)

Parents and students are asked to read and adhere to the “Code of Conduct” which can be found at www.northamptonshire.gov.uk along with the “Post 16 Transport Policy”.

I accept the “Code of Conduct” Date Signature of Student/Parent/Legal Guardian Print name

PAYMENT OPTIONS Year ½ Termly (1 invoice of £600) (6 invoices of £100 each)

DETAILS OF PARENT/LEGAL GUARDIAN (IF DIFFERENT FROM PERSON PAYING FOR TRANSPORT)

Title Mr/Mrs/Miss/Ms Forename(s) Surname

Address Town

County Post Code

Tel. No. Mobile No.

Email Address

Signature Date I have received and understood the “Travel Scheme for Post 16 Students 2016 – 2017 Guidance Notes” Print name

ARE YOU APPLYING FOR FINANCIAL SUPPORT? (Please circle) YES NO 2  To apply for financial support, please check your eligibility in accordance with the “Travel Scheme for Post 16 Students 2017-18 Guidance Notes”.  It is essential that you enclose documentary evidence to support your application. No financial support will be considered without this evidence therefore the full cost will be applied until these documents are received and your entitlement confirmed.  When sending your Tax Credit Awards, please ensure you enclose all pages of the original document.  Previous financial support does not guarantee financial support for this application.

ARE YOU IN RECEIPT OF FREE SCHOOL MEALS? If you are, you may qualify for financial assistance

(Please circle) YES NO

The information you supply may be verified with the School or the Free Schools Meals Team. To apply for Free School Meals please visit their website at www.northamptonshire.gov.uk

If you are on low income or in receipt of free school meals, you may be entitled to Bursary Funding, which is available from the establishment attended. Please note that this is not administered in this office

IMPORTANT INFORMATION

 Your application will be returned to you if not completed correctly. This may result in a delay in transport for your child.  If your child has reduced school hours it is your responsibility to transport your child. We may be able to accommodate travel one-way if the request is for a typical school / college start or finish time.  There are no refunds or reductions for travel used on a part time basis or not used through illness.  You will receive all Post 16 Application acknowledgments via email.  If your application is unsuccessful you will receive a letter explaining the reasons why and outlining any further steps available to you. .

PAYMENT DETAILS

If your application is successful, you will receive an invoice prior to the start of the academic year for the full cost of £600, if the yearly payment option has been chosen, or every school half term for £100 where the ½ termly payment option has been selected.

Details of where to direct your queries in relation to the charge and methods of payment will be shown on the reverse of your invoice. Regrettably, we are unable to process or check any payments in this office.

When you have completed the form please post it to: -

Northamptonshire Highways Post 16 Travel Scheme One Angel Square 4 Angel Street Northampton NN1 1ED

If you wish to email your completed application form please use an electronic signature to sign the declaration overleaf then email it to [email protected]

Please note for up to date information about Transport please visit the Local Offer and SNIX.

The Local Offer is a website that provides details of services and support available in Northamptonshire for children and young people with special 3 educational needs and disabilities. The Local Offer is also active on social media, Facebook and Twitter (look for LONorthants and our tree).

Use your Local Offer to find information for your family and to keep up to date with the latest news.

The SNIX magazine is produced by the Local Offer team as one of the ways to make sure the Local Offer is available to those who don’t have the internet.

For further information please contact the Local Offer www.northamptonshire.gov.uk/localoffer tel: 0300 126 1000 option 5: or e-mail [email protected]

OFFICE USE ONLY Receipt/Log Ack. emailed 50% Reduction Allocation/Issue Date Benefit Documents Date Free FSM Assessment Contract No N/Q Letter Date