MIFFLIN COUNTY SCHOOL DISTRICT
201 Eighth Street - Highland Park

TELEPHONE (717) 248-0148                            Lewistown, Pennsylvania  17044                                        FAX (717) 248-5345

Edward R. Curry, Director of Secondary Education
 Mark K. Hidlay, Director of Student Support Services

 James S. Weaver, Jr., Business Manager

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:                                                                         Address of Student:

__________________________________________     _____________________________________
First      Middle         Last
                                                                                                       ______________________________________ 

School: _________________________________           Bus/Van Number:______________

_________________________________________________ _______________________
Signature of Parent/Guardian Date

***************************************************************
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):
    HOME                                                                                                                    ______-__________

    Mother’s Name _________________________________________    ______-__________ WORK (Mother)

    Father’s Name __________________________________________    ______-__________ WORK (Father) 

    Guardian’s Name _______________________________________      ______-_________ WORK (Guardian)

Emergency Contact Person(s): Phone Numbers:

    Name/Relationship to Child _________________________________________    _____-__________ 

    Name/Relationship to Child _________________________________________     _____-__________

    Name of Child’s Physician _________________________________________        _____-__________

- 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

OFFICE USE ONLY

REV. 2/05

Distribution of this completed form is as follows: Two copies sent to the Assistant Superintendent
Original form will remain on file with the School Nurse