MIFFLIN COUNTY SCHOOL DISTRICT
			                        201 Eighth Street - Highland Park
TELEPHONE (717) 248-0148      	   Lewistown, Pennsylvania 17044                                   FAX (717) 248-5345


David S. Runk, Superintendent			                      Edward R. Curry, Director of Secondary Education 
Dr. John J. Czerniakowski, Assistant Superintendent          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