"Application Form for Permission to Travel - Public Transport Victoria" - Victoria, Australia

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Form  1:  Application  for  
Permission  to  Travel    
 
Students  
 
PLEASE   E NSURE   A LL   P AGES   A RE   C OMPLETED   A ND   S
IGNED  
Year  
       
 
Term  
       
 
 
APPLICANT   D
ETAILS  
RESIDENTIAL   A DDRESS  
Unit   #  
           
Street   #  
           
Address    
           
Town/Suburb  
           
State  
           
Postcode  
           
Exact   d istance   ( in   k m)   b y   t he   s hortest   p racticable   r oute  
From   h ome   t o   s chool  
                        k m  
From   h ome   t o   b us   s top  
            k m  
POSTAL   A DDRESS    
Unit/Street/PO   B ox   N umber  
           
Postal   A ddress  
           
Town/Suburb  
           
State  
           
Postcode  
           
PARENT/GUARDIAN   D ETAILS  
First   N ame  
           
Surname  
           
Telephone  
           
First   N ame  
           
Surname  
           
Telephone  
           
Email  
           
1.Name  
           
Relationship  
           
Telephone  
           
Emergency  
contacts  
2.Name  
           
Relationship  
           
Telephone  
           
 
TRAVELLER   D
ETAILS  
Student   o ne  
First   N ame  
           
Surname              
Date   o f   b irth  
           
Travel   s tart   d ate  
     
School   e nrolled  
           
Year   l evel   a t   t ime   o f   t ravel  
           
Any   m edical   p roblems   o r   r equirements   t he   d river   s hould   b e   n otified   o f?   I f   y es,   p lease   p rovide   d etails.  
           
Which   d ays   d o   y ou   i ntend   t o   u se   t his   s ervice?   ( please   u se   X   t o   h ighlight)  
MON  
 
TUE  
 
WED  
 
THU  
 
FRI  
 
Student   t wo  
First   N ame  
           
Surname              
Date   o f   b irth  
           
Travel   s tart   d ate  
     
School   e nrolled  
             
Year   l evel   a t   t ime   o f   t ravel  
           
Any   m edical   p roblems   o r   r equirements   t he   d river   s hould   b e   n otified   o f?   I f   y es,   p lease   p rovide   d etails.  
           
Which   d ays   d o   y ou   i ntend   t o   u se   t his   s ervice?   ( please   u se   X   t o   h ighlight)  
MON  
 
TUE  
 
WED  
 
THU  
 
FRI  
 
Student   t hree  
First   N ame  
           
Surname              
Date   o f   b irth  
           
Travel   s tart   d ate  
     
School   e nrolled  
             
Year   l evel   a t   t ime   o f   t ravel  
           
Any   m edical   p roblems   o r   r equirements   t he   d river   s hould   b e   n otified   o f?   I f   y es,   p lease   p rovide   d etails.  
           
Which   d ays   d o   y ou   i ntend   t o   u se   t his   s ervice?   ( please   u se   X   t o   h ighlight)  
MON  
 
TUE  
 
WED  
 
THU  
 
FRI  
 
 
 
 
 
 
 
Page   1   o f   4
Issued   O ctober   2 015
 
Form  1:  Application  for  
Permission  to  Travel    
 
Students  
 
PLEASE   E NSURE   A LL   P AGES   A RE   C OMPLETED   A ND   S
IGNED  
Year  
       
 
Term  
       
 
 
APPLICANT   D
ETAILS  
RESIDENTIAL   A DDRESS  
Unit   #  
           
Street   #  
           
Address    
           
Town/Suburb  
           
State  
           
Postcode  
           
Exact   d istance   ( in   k m)   b y   t he   s hortest   p racticable   r oute  
From   h ome   t o   s chool  
                        k m  
From   h ome   t o   b us   s top  
            k m  
POSTAL   A DDRESS    
Unit/Street/PO   B ox   N umber  
           
Postal   A ddress  
           
Town/Suburb  
           
State  
           
Postcode  
           
PARENT/GUARDIAN   D ETAILS  
First   N ame  
           
Surname  
           
Telephone  
           
First   N ame  
           
Surname  
           
Telephone  
           
Email  
           
1.Name  
           
Relationship  
           
Telephone  
           
Emergency  
contacts  
2.Name  
           
Relationship  
           
Telephone  
           
 
TRAVELLER   D
ETAILS  
Student   o ne  
First   N ame  
           
Surname              
Date   o f   b irth  
           
Travel   s tart   d ate  
     
School   e nrolled  
           
Year   l evel   a t   t ime   o f   t ravel  
           
Any   m edical   p roblems   o r   r equirements   t he   d river   s hould   b e   n otified   o f?   I f   y es,   p lease   p rovide   d etails.  
           
Which   d ays   d o   y ou   i ntend   t o   u se   t his   s ervice?   ( please   u se   X   t o   h ighlight)  
MON  
 
TUE  
 
WED  
 
THU  
 
FRI  
 
Student   t wo  
First   N ame  
           
Surname              
Date   o f   b irth  
           
Travel   s tart   d ate  
     
School   e nrolled  
             
Year   l evel   a t   t ime   o f   t ravel  
           
Any   m edical   p roblems   o r   r equirements   t he   d river   s hould   b e   n otified   o f?   I f   y es,   p lease   p rovide   d etails.  
           
Which   d ays   d o   y ou   i ntend   t o   u se   t his   s ervice?   ( please   u se   X   t o   h ighlight)  
MON  
 
TUE  
 
WED  
 
THU  
 
FRI  
 
Student   t hree  
First   N ame  
           
Surname              
Date   o f   b irth  
           
Travel   s tart   d ate  
     
School   e nrolled  
             
Year   l evel   a t   t ime   o f   t ravel  
           
Any   m edical   p roblems   o r   r equirements   t he   d river   s hould   b e   n otified   o f?   I f   y es,   p lease   p rovide   d etails.  
           
Which   d ays   d o   y ou   i ntend   t o   u se   t his   s ervice?   ( please   u se   X   t o   h ighlight)  
MON  
 
TUE  
 
WED  
 
THU  
 
FRI  
 
 
 
 
 
 
 
Page   1   o f   4
Issued   O ctober   2 015
 
OFFICE   U SE   O NLY  
Date   F orm   S ubmitted  
           
Form   S igned   -­‐   Y es/No   –   i f   n o,   r eturn   t o   P arent/Guardian   f or   s ignature  
Date   F orm   c ompleted  
           
Parent/Guardian   s igned?  
           
Eligibility   a ssessed   -­‐   Y /N?  
           
Application   ( s)  
Waitlisted   -­‐   Y /N?  
           
Student(s)   s igned?  
           
           
Approved/Declined  
Have   a ny   o f   t hese   s tudents   b een   g ranted   e ligibility   o n   t he   b asis   o f   a n   e xemption?   I f   y es,   s pecify   e xemption   f rom   p olicy.  
Student   o ne  
           
Student   t wo  
           
Student   t hree  
           
Eligibility   S tatus   ( Eligible   =   E ,   N ot   E ligible   =   N E,   E xemption   G ranted   =   E G   o r   F are   P ayer   =   F P   a nd   F are   A mount   e .g.   F P   a t   $ 180   p er   t erm)  
Student   o ne  
           
Student   t wo  
           
Student   t hree  
           
Fare   P ayment   r equired   – Y/N?  
           
Has   P arent/Guardian   b een   i nvoiced?   Y /N  
           
Date    
           
Fares   c ollected   –   Y /N?  
 
Has   P arent   b een   n otified   i n   w riting   o f   t ravel   s tatus?  
           
Date  
           
BUS   S ERVICE   D
ETAILS  
AM   B us   S ervice   ( s)  
Bus   r oute   a llocated  
           
Bus   o perator  
           
Interchange   d etails   -­‐ if   r eq.  
           
Bus   o perator  
           
Pick-­‐up   b us   s top   l ocation  
           
Pick   u p   t ime  
           
Drop   o ff   b us   s top   l ocation  
           
Drop   o ff   t ime  
           
Seat   n umber   a llocated  
           
Bus   r oll   u pdated  
           
Comments:  
           
PM   B us   S ervice   ( s)  
Bus   r oute   a llocated  
           
Bus   o perator  
           
Interchange   d etails   -­‐ if   r eq.  
           
Bus   o perator  
           
Pick-­‐up   b us   s top   l ocation  
           
Pick   u p   t ime  
           
Drop   o ff   b us   s top   l ocation  
           
Drop   o ff   t ime  
           
Seat   n umber   a llocated  
           
Bus   r oll   u pdated  
           
Comments:  
           
 
OFFICE   U SE   O NLY  
School   B us   C oordinator   N ame   ( please   p rint):                  
School   S ignature   –   C oordinating   P rincipal   /   D elegate   s ignature:                  
Date                  
 
 
 
 
 
 
 
Page   2   o f   4
Issued   O ctober   2 015
 
Conditions  of  Travel  
To   e nsure   t he   s afety   o f   a ll   p assengers   o n   s chool   b uses,   t he   f ollowing   c onditions   a pply   a t   a ll   t imes.  
To   e nsure   s afe   t ravel   o n   s chool   b uses,   s tudents   m ust   a gree   t o   t he   f ollowing:  
•   Not   t o   p lay   o n   t he   r oad   a t   t he   b us   s top   o r   t ry   t o   g et   o n   t he   b us   b efore   i t   h as   s topped.  
•   Make   s ure   y ou   a nd   y our   b elongings   a re   i nside   t he   b us   a t   a ll   t imes.  
•   Not   t hrow   a nything   f rom   a   b us   w indow   o r   h ave   a nything   h anging   o ut   a   w indow.  
•   Place   b ags   a nd   o ther   b elongings   i n   t he   a llocated   s torage   a reas.  
•   Get   o n   a nd   o ff   t he   b us   q uietly   a nd   i n   a n   o rderly   m anner.  
•   Stay   i n   y our   s eat   w hile   t he   b us   i s   m oving.  
•   Not   d istract   d rivers   w ith   s creaming,   s houting   o r   u nruly   b ehaviour.  
•   When   y ou   g et   o ff   t he   b us   o nly   c ross   t he   r oad   w hen   t he   b us   h as   l eft   a nd   i t   i s   s afe   t o   d o   s o.  
•   No   d angerous   o r   f lammable   g oods   a re   a llowed   o n   t he   b us,   f or   e xample   a erosol   c ans.  
•   Travel  on  the  bus  service  allocated  to  you,  to  and  from  your  approved  bus  stop  only.    Do  not  change  to  one  that  will  
take   y ou   t o   a   s ports   o r   s ocial   e vent.  
•   Wear   a   s eat   b elt   w here   f itted.  
To   e nsure   s tudents   a re   c onsiderate   t o   o ne   a nother   a nd   t heir   b us   d river,   t hey   m ust   a gree   t o:  
•   In   t he   m orning,   a rrive   a t   t he   b us   s top   1 0   m inutes   p rior   t o   d eparture.  
•   Not   e at,   d rink   o r   s moke   w hile   o n   t he   s chool   b us.  
•   In   t he   m orning,   l et   t he   s chool   a nd   d river   k now   i f   y ou   w ill   n ot   b e   t ravelling   h ome   o n   t he   b us   t hat   d ay.  
•   Use   a   s tandard   c onversational   t one   a nd   n ot   u se   o ffensive   l anguage   o r   c all   o ut   t o   o thers   o n   b oard   o r   t o   p assing   t raffic   o r  
people.  
•   Listen   to   the   bus   driver   and   bus   captain.     They   are   responsible   for   maintaining   school   bus   safety   and   also   have   the  
authority   t o   r eport   a ny   v andalism   o r   m isbehaviour   i ncluding   b ut   n ot   l imited   t o   b ullying,   t easing,   o r   a ggression.  
•   Leave   your   bike   in   a   safe   and   secure   place   if   riding   to   the   bus   stop.   Public   Transport   Victoria   and   the   Department   of  
Education   a nd   T raining   a re   u nable   t o   a ccept   r esponsibility   f or   t he   s afety   o f   y our   b ike.  
•   Behaving   i nappropriately   o n   a   s chool   b us   p laces   t he   s afety   a nd   w ellbeing   o f   a ll   o n   b oard   a t   r isk.  
Non-­‐compliance   w ith   a ny   o f   t he   a bove   c onditions   m ay   r esult   i n   t he   f ollowing:  
•   The   d river   w ill   s top   t he   b us.  
•   The   o ffender’s   n ame   a nd   f ull   d etails   o f   t he   b reach   w ill   b e   r ecorded.  
•   The   o ffender   w ill   b e   t ransported   t o   s chool   o r   t o   t heir   n ormal   d rop   o ff.  
•   The   b reach   w ill   b e   r eported   t o   t he   c oordinating   p rincipal.  
•   The   c oordinating   p rincipal   w ill   t ake   d isciplinary   m easures   i n   a ccordance   w ith   t he   g uidelines   b elow.  
•   In   r are   a nd   e xceptional   c ircumstances,   a nd   o nly   a s   a   l ast   r esort,   d rivers   a re   a uthorised   t o   e ject   p assengers   f rom   a   b us.    
Following   t he   r eport   o f   a   r elevant   i ncident,   t he   c oordinating   p rincipal   m ay   t ake   t he   d isciplinary   a ction   b elow:  
•   First   o ffence    
–   v erbal   w arning   t o   s tudent.  
•   Second   o ffence     –   w ritten   w arning   t o   p arent/guardian.  
•   Third   o ffence    
–   o ne   w eek   s uspension   o f   s tudent   f rom   s chool   b us   t ravel.  
•   Fourth   o ffence     –   t he   s tudent   w ill   n ot   b e   a llowed   t o   t ravel   o n   t he   s chool   b us   f or   t he   r emainder   o f   t he   y ear.  
A   s erious   o ffence   t hat   e ndangers   o ther   s tudents,   b us   s taff   o r   p roperty   w ill   r esult   i n   i mmediate   s uspension.  
Responsibilities   o f   p arents/guardians  
•   Parents/guardians  are  responsible  for  transporting  their  children  to  and  from  authorised  bus  stops  and  their  safety  at  
the   b us   s top   w hile   w aiting   f or   t he   b us.  
•   It   i s   m ost   i mportant   t hat   p arents   w aiting   f or   b us   p assengers   a t   a   r oadside   b us   s top   s hould   w ait   o n   t he   s ame   s ide   o f   t he  
road   a s   t he   b us   t o   p revent   a ccidents.  
•   School   b us   t ravel   i s   a   p rivilege   a nd   n ot   a   r ight   a nd   c onsequences   w ill   f ollow   a   b reach   o f   t hese   c onditions.      
•   It   i s   u nderstood   t hat   b us   t ravel   i s   p rovided   a nd   a ccepted   o n   t hese   c onditions.  
 
 
 
 
 
 
Page   3   o f   4
Issued   O ctober   2 015
 
 
PARENT/GUARDIAN   T O   C OMPLETE:  
I   c ertify   t hat:  
1.   All   t he   a bove   d etails   a re   t rue   a nd   c orrect.  
2.   I   w ill   n otify   t he   p rincipal   i n   w riting   w ithin   7   d ays   o f   a ny   c hange   o f   a ddress   o r   s chool.    
3.   I   a gree   t o   p ay   t he   c osts   o f   r epairs   o r   d amage   t o   t he   b us,   o r   i ts   r eplacement   i f   t otally   d estroyed,   c aused   b y  
the   v andalism   o r   d eliberate   a ct   o f   m y   c hild(ren).  
4.   I   c onsent   t o   r elease   t his   i nformation   t o   P ublic   T ransport   V ictoria   ( PTV)   t o   a ssist   w ith   p lanning   f or   t ransport  
services.  
I   a ccept   t he   a uthority   o f   t he   c oordinating   p rincipal   w ith   r egard   t o   s tudent   d iscipline   o n   t he   s chool   b us   s ervice.  
I   a gree   t o   a bide   b y   t he   a bove   C onditions   o f   T ravel.  
I   u nderstand   t hat   i f   I   o r   m y   c hild(ren)   d o   n ot   c omply   w ith   t he   C onditions   o f   T ravel,   i t   m ay   r esult   i n   m y   c hild(ren)   n ot  
being   p ermitted   t o   t ravel   o n   t he   s chool   b us   s ervice.  
Parent/guardian   n ame   ( please   p rint)                  
Parent/guardian   s ignature                  
Date                  
 
STUDENT   ( s)   T O   C OMPLETE:  
I   a ccept   t he   a uthority   o f   t he   c oordinating   p rincipal   w ith   r egard   t o   s tudent   d iscipline   o n   t he   s chool   b us   s ervice.  
I   a gree   t o   a bide   b y   t he   a bove   C onditions   o f   T ravel.  
Student  
Student   o ne  
Student   t wo  
Student   t hree  
Print   N ame  
 
 
 
Signature  
 
 
 
Date  
 
 
 
 
 
 
 
 
Page   4   o f   4
Issued   O ctober   2 015
 
Page of 4