The purpose of this form is to give school bus drivers and/or emergency medical technicians information about children who have special needs or medical conditions.  One copy of this form is kept in the nurse’s office and another copy is kept on the student’s school bus in a secure location for bus drivers and emergency medical technicians.  If the emergency care of the student requires medication, the parent/guardian must file a School Medical Authorization Form with the school nurse.

To be completed by the student’s parent/guardian:

My child’s special needs are: (list behavioral or communication challenges and required responses)

My child requires medication for: (describe conditions and circumstances)

AMENDED:    August 1, 2014