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Glenbard Township High School District 87
Policy 4:110-E3

Operational Services

Exhibit – Emergency Medical Information for Students Having Special Needs and/or Medical Conditions Who Ride Special Needs School Buses

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:

Student's Name (Please print)   
                                Birth Date      

Parent/Guardian's Name  
                                Home Phone
                               Cell Phone      


Physician's Name
                                Physician's Phone
                               School Nurse's Phone

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

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


Parent/Guardian Signature

ADOPTED:     March 24, 2015