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Colchester Public Schools
Emergency Medical Information Release Form For Bus Drivers
If your child has a medical condition that could potentially cause a life threatening emergency
while he/she is being transported by the school bus, please advise the applicable school nurse
by completing the form below. This form serves as a release for the school district to provide
the medical information provided to the district’s bus company It is the responsibility of the
parent or guardian to provide the School Nurse with this information.
If applicable, please complete the form below and return the form to the School Nurse at the
school your student attends. A copy of the form will be forwarded to the district’s bus company
and the medical information will be relayed to your child’s bus driver by the bus company.
A new form must be submitted every school year.
STUDENT NAME: DATE of BIRTH:
SCHOOL: GRADE: BUS #:
HOME ADDRESS:
MEDICAL CONDITION:
POTENTIAL EMERGENCY, EXPECTED SYMPTOMS or OBSERVATIONS:
DOES YOUR CHILD CARRY AN EpiPen®? YES NO
IF YES, WHERE IS IT KEPT (POCKET, BACKPACK, ETC.):
Please understand that the bus driver’s primary responsibility is to safely transport students.
Bus drivers do not provide first aid or medical treatments. However, all of the school district’s
bus company drivers are trained in the use of an EpiPen® and are authorized to use a student’s
personal EpiPen® if an allergic emergency (anaphylaxis) occurs. The purpose of this document
is to provide the bus drivers with information which would assist them to identify emergency
situation as early as possible so that the appropriate medical assistance can be contacted in a
timely manner.
PARENT / GUARDIAN SIGNATURE: DATE:
PARENT PHONE #s: CELL: HOME:
SCHOOL NURSE USE ONLY:
DATE RECEIVED: DATE FORWARDED TO BUS CARRIER: