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Copyright
© 2009 MCSD. All rights reserved.
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M IFFLIN COUNTY SCHOOL DISTRICT201 Eighth Street - Highland Park TELEPHONE (717) 248-0148 Lewistown, Pennsylvania 17044 FAX (717) 248-5345David S. Runk, Superintendent Dr. John J. Czerniakowski, Assistant Superintendent Tracey M. Jones, Director of Special Education Edward R. Curry, Director of Middle Level Education James S. Weaver, Jr., Business Manager Sean A. Daubert, Chief Financial Officer Lisa L. Lyles, Director of Human Resources 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 beingtransported 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 SECTION II: EMERGENCY TELEPHONE NUMBERS (S OMEONE 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______________________CELLWORK (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 - Educate each student to meet life’s challenges. 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 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? 1 st___________________________________________________________________________________2 nd___________________________________________________________________________________3 rd___________________________________________________________________________________4 th___________________________________________________________________________________I give permission to distribute a copy of this completed form to my child’s bus/van driver. _______________________ Signature of Parent/Guardian Date Revised: 8/08
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