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Bus Emergency Medical Information and Form Deer Creek-Mackinaw CUSD #701 |
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Deer Creek-Mackinaw CUSD #701 is requesting your assistance in addressing a safety concern regarding transporting your child on the bus. When your child is at school, important medical information is readily available in the office in case of an emergency. That information is not available on the bus for the driver or emergency personnel if it were needed. We are requesting that you complete an Emergency Medical Information Form for each of your children. It is important that a separate form be completed for each child. The form will be used for regular routes and field trips. A form just be completed for each child because there is a good possibility that your child will be taking a field trip sometime during the school year. This is a legal requirement and your cooperation is appreciated. The information will be kept on the bus in a secure location or with the classroom teacher during field trips available only in the case of an emergency. |
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Bus Emergency Medical Information Form Deer Creek-Mackinaw CUSD #701 |
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Bus Emergency Medical Information Form Office use: Deer Creek-Mackinaw CUSD #701 Driver:_______________ Bus # This form is to be completed for all students! The purpose of this form is give school bus drivers and/or emergency medical technicians information about children who have special needs or medical conditions.
_____ NO My child does not have any medical condition or special need that emergency medical technicians should know.
Student’s Name (please print):_________________________________ Grade:_____ Teacher:____________
___________________________ _____________________________ _____________ Parent(s)/Guardian(s) Printed Name Parent(s)/Guardian(s) Signature Date
Please initial below:
_____ I have completed and filed in the principal’s office a School Medical Authorization Form.
_____ I authorize the School District, and its employees and agents, to take the action they believe is appropriate under the circumstances.
_____ I agree to indemnify and hold harmless the School District, and its employees and agents, against any claims, except a claim based on willful and wanton conduct, arising out of the emergency care of my child. _____YES My child does have a medical condition or special need that emergency medical technicians should know.
Student’s Name (Please print)___________________________ Grade:_____ Teacher: ________________
Date of Birth:__________ Home Phone______________ Emergency Phone_____________ Cell Phone__________
Physician’s Name_________________ Office Phone_________________Emergency Phone_______________
If relevant, special circumstances under which medication should be given:
Student’s special needs (medical or behavioral):
Expected communication challenges:
How should medical personnel respond to your child’s special needs:
Please initial below:
_____ I have completed and filed in the principal’s office a School Medical Authorization Form.
_____ I authorize the School District, and its employees and agents, to take the action they believe is appropriate under the circumstances.
_____ I agree to indemnify and hold harmless the School District, and its employees and agents, against any claims, except a claim based on willful and wanton conduct, arising out of the emergency care of my child.
___________________________ _____________________________ _____________ Parent(s)/Guardian(s) Printed Name Parent(s)/Guardian(s) Signature Date
One copy of this form will be kept in the principal’s office and another copy will be kept on the student’s school bus or by classroom teacher in a secure location for emergency medical techni
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