NETRIBUS Emergency Intervention Release Form

INSTRUCTIONS :

District

School

Grade

Student Last Name

Student First Name

Gender

Birth Date

Student ID

Alternate ID

Student Information

Class/Home Room

Teacher

Health Card Number

Mother/guardian

Telephone (home)

Telephone (work)

Telephone (emergency)

Father/guardian

Telephone (home)

Telephone (work)

Telephone (emergency)

Family Doctor

Telephone

Care Giver

Telephone

Emergency Contact

Telephone

Allergies: List any allergies which may result in anaphylactic shock.

Symptoms: List any known symptoms which may be a precursor to anaphylaxis shock.

Location of EpiPen

Photo

Section 2 – Informed Consent of Parent/Guardian

Confirmation Required

I hereby acknowledge, that at my request, the school bus driver and/or the school bus attendant have been authorized to administer, in a life-threatening situation, the following medication/procedure to my son/daughter.

Name of Medication/Procedure

Method of Administration

Authorization for the collection of this information is in the Education Act. Users will be the Principal, Teacher, School Bus Operator, School Bus Driver, School Bus Attendant and appropriate school support staff for the purpose of obtaining parental consent and direction for life-threatening situations. This form will be retained in the school office for as long as is deemed necessary. Contact person for queries concerning this information is the Principal of the school.

Request for Confirmation

And, I hereby release the school bus operator, school bus driver, school bus attendant and the North East Tri-Board Student Transportation group (District School Board Ontario North East, Northeastern Catholic District School Board and Conseil scolaire public du Nord-Est de l'Ontario) and each of their respective employees, officers and agents from any liability in the same manner as provided in Section 3, subparagraph (4) of Sabrina's Law, 2005, S.O. 2005, Chap. 7 which provides “No action for damages shall be instituted respecting any act done in good faith or for any neglect or default in good judgment in response to an anaphylactic reaction in accordance with this Act, unless the damages are the result of an employee's gross negligence”, it being specifically agreed by me that any act done or not in furtherance of the instruction given herein should have the same protection as extended to school board employees by Sabrina's Law.

Submitted by I acknowledge that transportation procedures will apply.

Last Name

First Name

NETRIBUS Emergency Intervention Release Form

INSTRUCTIONS :

More than one student matches the criteria submitted. Please select the student to use

Student Information

Mother/guardian

Father/guardian

Section 2 – Informed Consent of Parent/Guardian

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