Life Threatening Emergency Medical Form For School And Transportation Use

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Please Check One:
Student is a Walker
Student Rides the Bus
Life Threatening Emergency Medical Form
For School and Transportation Use
1.
Use of this form is limited ONLY TO STUDENTS WITH LIFE-THREATENING MEDICAL CONDITIONS that may require the
emergency administration of an epinephrine auto-injector or other emergency medical attention.
2.
This form shall contain a clear and recent photograph of the student.
3.
Please ensure that this form is filled out completely, legibly and in pen.
4.
This form should be updated yearly and/or as medical information changes.
5. NOTE: Bus companies do not provide epinephrine auto-injectors on the school bus/vehicle. It is the responsibility of
the parent(s)/guardian(s) to ensure that their child carries an auto-injector if it is required. Bus drivers are trained in
administrating an auto-injector.
Student Name:
Parent(s)/Guardian(s):
Civic Address:
Student Photo
Primary Emergency Contact #:
Secondary Contact #:
Alternate #:
School:
Grade:
Bus Company:
Route #:
Life Threatening Medical Condition(s):
Allergy/Anaphylaxis to
:
(specify allergy/allergies)
Auto-injector can be found (Please indicate
location of auto-injector on student):
Asthma (specify type of reliever inhaler):
Inhaler can be found (Please indicate location of
inhaler on student):
Other Medical Condition(s)
(please specify condition(s) and location(s) of any support devices):
I/we authorize this “Life Threatening Emergency Medical Form” to be shared with school staff, bus companies, bus
drivers and Student Transportation of Eastern Ontario (STEO).
Parent(s)/Guardian(s) Signature
Date
FOR STUDENTS WHO ACCESS TRANSPORTATION, I hereby confirm that the school has received the Administration of
Medication Form and that discussions were held with the parent(s)/guardian(s) and the bus company and/or bus driver
to review the transportation emergency action plan for the child identified on this form.
Principal’s Signature
Date
 School Office Administrator for Student File
Copy to:
Bus
Copy (if applicable) to:
STEO (Fax: 613-925-0024)
Company/Driver
Reviewed: June 2016
Administrative Procedure – B1:2
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