FORMTEXT
PROCEDURES TO FOLLOW FOR MEDICAL EMERGENCY
WHILE BEING TRANSPORTED TO AND FROM SCHOOL
Dear Parent:
In an attempt to better serve your child in the event of a medical emergency while on school transportation to/from school, we would ask that you complete the form below. If your child is at a greater risk for a medical emergency while being transported to and from school, complete all sections of this form.
This form must be completed and returned to your child’s school nurse.
SECTION I:
|
Name of Student:
________________ __________ _________________ First Middle Last |
Address of Student:
|
|
School: |
Bus/Van Number: |
__________________________
Signature of Parent/Guardian Date
f f f f f f f f f f f f f f f f f f f f f f f f
SECTION II:
|
EMERGENCY TELEPHONE NUMBERS (Someone MUST be at one of the numbers listed below during the time of transportation to and from school) |
|
|
Parent/Guardian Phone Number(s):
Mother’s Name ___________________________________ Father’s Name ____________________________________ Guardian’s Name _________________________________ |
_____________ HOME______________________CELL
WORK (Mother)______________CELL WORK (Father)_______________CELL WORK (Guardian)_____________CELL |
|
Emergency Contact Person(s):
Name/Relationship to Child _____________________________________ Name/Relationship to Child ____________________________________ Name of Child’s Physician ______________________________________ |
Phone Numbers:
______________HOME____________CELL ______________HOME____________CELL ______________HOME____________CELL |
- CONTINUED ON REVERSE SIDE -
SECTION III:
|
A. |
Child’s Medical Condition:
|
|
B. |
What would the driver observe in the event of a medical concern/emergency with your child on the bus/van?
|
|
C. |
Is medication available to the bus/van driver in case of an emergency? If so, where is it kept? |
|
D. |
What is the driver expected to do to help your child with a medical problem on the bus or at the bus stop?
1st___________________________________________________________________________________ 2nd___________________________________________________________________________________ 3rd___________________________________________________________________________________ 4th___________________________________________________________________________________ |
I give permission to distribute a copy of this completed form to my child’s bus/van driver.
_______________________
Signature of Parent/Guardian Date
|
Distribution of this completed
form is as follows:
Two copies sent to the Coordinator
of Transportation
Original form will remain on file
with the School Nurse |
Revised: 8/08
FORMTEXT
PROCEDURES TO FOLLOW FOR MEDICAL EMERGENCY
WHILE BEING TRANSPORTED TO AND FROM SCHOOL
Dear Parent:
In an attempt to better serve your child in the event of a medical emergency while on school transportation to/from school, we would ask that you complete the form below. If your child is at a greater risk for a medical emergency while being transported to and from school, complete all sections of this form.
This form must be completed and returned to your child’s school nurse.
SECTION I:
|
Name of Student:
________________ __________ _________________ First Middle Last |
Address of Student:
|
|
School: |
Bus/Van Number: |
__________________________
Signature of Parent/Guardian Date
f f f f f f f f f f f f f f f f f f f f f f f f
SECTION II:
|
EMERGENCY TELEPHONE NUMBERS (Someone MUST be at one of the numbers listed below during the time of transportation to and from school) |
|
|
Parent/Guardian Phone Number(s):
Mother’s Name ___________________________________ Father’s Name ____________________________________ Guardian’s Name _________________________________ |
_____________ HOME______________________CELL
WORK (Mother)______________CELL WORK (Father)_______________CELL WORK (Guardian)_____________CELL |
|
Emergency Contact Person(s):
Name/Relationship to Child _____________________________________ Name/Relationship to Child ____________________________________ Name of Child’s Physician ______________________________________ |
Phone Numbers:
______________HOME____________CELL ______________HOME____________CELL ______________HOME____________CELL |
- CONTINUED ON REVERSE SIDE -
SECTION III:
|
A. |
Child’s Medical Condition:
|
|
B. |
What would the driver observe in the event of a medical concern/emergency with your child on the bus/van?
|
|
C. |
Is medication available to the bus/van driver in case of an emergency? If so, where is it kept? |
|
D. |
What is the driver expected to do to help your child with a medical problem on the bus or at the bus stop?
1st___________________________________________________________________________________ 2nd___________________________________________________________________________________ 3rd___________________________________________________________________________________ 4th___________________________________________________________________________________ |
I give permission to distribute a copy of this completed form to my child’s bus/van driver.
_______________________
Signature of Parent/Guardian Date
|
Distribution of this completed
form is as follows:
Two copies sent to the Coordinator
of Transportation
Original form will remain on file
with the School Nurse |
Revised: 8/08
