Walking School Bus Program - BSS pilot

1. PRE-REGISTRATION FORM

This Walking School Bus program is a pilot project that is being funded by HRCE-Health Promoting Schools, and will run for only 4 weeks to encourage more children to walk to school led by a volunteer adult supervisor (either a guardian, parent or a senior living in the area).

The program is free, and open to all students whose parents are

a) interested in participating, and

b) willing to serve as trained leaders for the group in their neighbourhood at least once a week.

The Walking School Bus will operate daily in the morning only (or 2-3 times a week if not enough volunteers are able to lead the students everyday), from May 27 to June 21.

Walking routes and groups will be determined based on participants' address and not to exceed 1-1.5 km or 10-15 min walking distance to school.

Students who live over 1.5 km are welcome to join as long as parents or guardians are willing to drive them to one of the designated Walking School Bus stops along the way.

By filling out this form, you are only expressing interest in taking part in this pilot, and agree for Natalia Diaz-Insense, BBS's Walking School Bus program coordinator, to contact you to confirm participation and clarify any details related to coordinating and evaluating the project.

A note about privacy: All personal information collected will be kept strictly confidential and only be used for the purposes outlined above.

Question Title

* 1. Participating Child(ren)'s Name & Grade (GP, G1, G2, G3, G4, G5, G6).
Example: Smith, Richard, G1

Child 1: Name & Grade (Last, First, Grade)

Child 2: Name & Grade (Last, First, Grade)

Child 3: Name & Grade (Last, First, Grade)

Child 4: Name & Grade (Last, First, Grade)

Question Title

* 2. Does/do your child/children currently walk to school on a regular basis?

Yes, always

Yes, sometimes (once or twice a week)

No, only occasionally

No, never

Question Title

* 3. Contact Information - Parent/Guardian 1

Last Name

First Name

Address

City

Province

Postal Code

Email Address

Home Phone Number

Work Phone Number

Cell Phone Number

Question Title

* 4. Contact Information - Parent/Guardian 2

Last Name

First Name

Address

City

Province

Postal Code

Email Address

Home Phone Number

Work Phone Number

Cell Phone Number

Question Title

* 5. Emergency Contact Information

Name

Relationship to Student

Emergency Contact Phone number

Question Title

* 6. Health Information. Are there any allergies, medical information or anything else that the Walking School Bus leader should know? If so, please describe.

Question Title

* 7. Are you able to become a Walking School Bus leader? If not, please select NO to all the options below. And if so, please select yes/no according to your availability or preference.

	Monday	Tuesday	Wednesday	Thursday	Friday
YES	YES Monday	YES Tuesday	YES Wednesday	YES Thursday	YES Friday
NO	NO Monday	NO Tuesday	NO Wednesday	NO Thursday	NO Friday

Other (please specify)

Question Title

* 8. A current Criminal Records Check and a Child Abuse Register Form (completed within the last 3 years) are both required to be on file at school from all parents/guardians and caregivers who take part on this Walking School Bus project. A letter from Bedford South School is available from the main office to apply for the Criminal Records Check for a reduced fee. The Child Abuse Register Form is free. Please let us know if you have both of them on file.

	Yes	No
Criminal Records Check (Halifax Regional Police) - cost $30	Criminal Records Check (Halifax Regional Police) - cost $30 Yes	Criminal Records Check (Halifax Regional Police) - cost $30 No
Child Abuse Registry Form (NS Dept. of Community Services) - free	Child Abuse Registry Form (NS Dept. of Community Services) - free Yes	Child Abuse Registry Form (NS Dept. of Community Services) - free No

Comments (please specify)

Walking School Bus Program - BSS pilot

1. PRE-REGISTRATION FORM

Question Title

* 1. Participating Child(ren)'s Name & Grade (GP, G1, G2, G3, G4, G5, G6).Example: Smith, Richard, G1

Question Title

* 2. Does/do your child/children currently walk to school on a regular basis?

Question Title

* 3. Contact Information - Parent/Guardian 1

Question Title

* 4. Contact Information - Parent/Guardian 2

Question Title

* 5. Emergency Contact Information

Question Title

* 6. Health Information. Are there any allergies, medical information or anything else that the Walking School Bus leader should know? If so, please describe.

Question Title

* 7. Are you able to become a Walking School Bus leader? If not, please select NO to all the options below. And if so, please select yes/no according to your availability or preference.

Question Title

Question Title

* 9. Full Name of person completing this form

* 1. Participating Child(ren)'s Name & Grade (GP, G1, G2, G3, G4, G5, G6).
Example: Smith, Richard, G1