Independent Travel Training

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Progress

About you (the referrer)

Full name of referrer

Given name and family name

Address

Postcode

Find Address

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Select Address -- Please select --

 

Address line 1

Address line 2 (optional)

City

Postcode

Clear postcode/address

Use the Lookup Postcode button to find the address.

If you cannot find the address, please enter it manually

Email address

Telephone number

No information is required, please proceed to the next page.

About the young person

Full name

Given name and family name

Date of birth

Home address

Postcode

Find Address

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Select Address -- Please select --

 

Address line 1

Address line 2 (optional)

City

Postcode

Clear postcode/address

Use the Lookup Postcode button to find the address.

If you cannot find the address, please enter it manually

Have they travelled independently before?

Yes

No

Please provide details

Have they received Travel Training before?

Yes

No

Please provide details

Do they receive transport through the Local Authority Transport Team?

Yes

No

Please provide details

Is this by taxi or bus? -- Please Select -- Taxi Bus

Do they have a travel pass?

Yes

No

Is there anybody that the young person must not come into contact with or that we should be aware of?

Yes

No

Don't know

Please give details

Additional information: Motivation to make the journey / confidence / personality traits (optional)

No information is required, please proceed to the next page.

Further information

Does the young person:

Have any medical issues?

Yes

No

Not Known

Please provide details

Have any physical or sensory disabilities?

Yes

No

Not Known

Please provide details

Have any allergies or phobias?

Yes

No

Not Known

Please provide details

Have any issues relating to behaviour?

Yes

No

Not Known

Please provide details

Have an increased dependency on support?

Yes

No

Not Known

Please provide details

Can the young person:

Recognise the dangers of crossing the road?

Yes

No

Not Known

Please provide details

Use a light controlled and/or pedestrian crossing?

Yes

No

Not Known

Please provide details

Cross safely without using a recognised crossing?

Yes

No

Not Known

Please provide details

Learn to remember routes and directions?

Yes

No

Not Known

Please provide details

Read a bus number / destination?

Yes

No

Not Known

Please provide details

Request help from an appropriate source?

Yes

No

Not Known

Please provide details

Deal appropriately with strangers?

Yes

No

Not Known

Please provide details

Maintain their own personal safety?

Yes

No

Not Known

Please provide details

No information is required, please proceed to the next page.

Journey details

Tell us the location the young person will be travelling from and to each day. For example, from 'Home address' to 'Croxteth Primary School'

From

To

Return journey required

Yes

No

Days, start and finish times

Tell us which days the young person will be travelling, the time they leave for school and the school finish time. If times are the same daily, tick the checkboxes for each day and give a start and end time. If times are different on any days, select 'Add another set' to add different days and times.

Select days

Mon

Tues

Wed

Thur

Fri

Sat

Sun

Start time

End time

No information is required, please proceed to the next page.

Parent / Carer details

Parent/Carer full name

Enter full name

Telephone number

Other information - Please comment on anything relevant that has not been included on this form already: (optional)

Emergency contact details if parent/carer are not available

Add emergency contact details

Emergency contact full name (optional)

Given name and family name

Emergency contact number (optional)

Add emergency contact

No information is required, please proceed to the next page.

Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page

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