MEDICAL REQUEST FOR TRANSPORTATION
The Parent or Guardian of
(Student ID Number or Birthdate)
is requesting special transportation consideration for his/her child to
ALL INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL
In your professional opinion, does this student suffer from any condition that would physically prohibit his/her
walking to school thus requiring transportation?
(Transportation requirements: two miles – elementary, two miles- middle school and three miles – high school.)
A physician must attach a detailed statement of medical diagnoses, medication, duration, and any other
supporting evidence why special transportation is necessary for the student. CMSD policy requires a
physical to be completed on all students each year; please include a physical with this report. Include
information on how walking to school aggravates the student’s condition.
Physician Name: Telephone:
RELEASE OF INFORMATION: I hereby authorize the Medical/Mental Health Professional named above to
release the requested information to the Cleveland Municipal School District. I further authorize the District to
submit this information to the District’s Health Services Office. A copy of this authorization is as valid as the
original. Such information may also become a part of the student’s school health record.
Signature of Parent/Guardian Date
RETURN TO: (Before September 1
): Health Services, 1671 East 71
Cleveland, Ohio 44103
Phone: 216-361-8142 Fax: 216-361-8122
(After September 1
): Return to your School Nurse