RCJTC ReasonForSpecialTransportation

District

School

Grade

Student Last Name

Student First Name

Gender

Birth Date

Student ID

Alternate ID

Reason for Special Transportation

Is the student restricted in his/her activities at school?

If yes, please explain any reduction in physical activities and/or other restrictions while at school.

Is this student capable of walking the above distance to/from school or bus stop? If no, please complete the following section.

a. Explain the nature of the medical condition, in detail.

b.Transportation is neccessary for the following period:

From

Is your child Anaphylactic? Is your child Diabetic?

Student Photo

Emergency Contacts

		Name:	(H)	(W)	(C)
	1.

		Name:	(H)	(W)	(C)
	2.

		Name:	(H)	(W)	(C)
	3.

Anaphylaxis Emergency Treatment Plan

Student has a potentiall life-threatening allergy (anaphylaxis) to the following:

Peanut

Tree Nuts

Wheat

Egg

Milk

Latex

Insect Stings (bees/wasp)

Other:

Medical:

Parent/Guardian grants permission for a copy of this form to be given to their child's driver, where applicable.
All drivers have First Aid/CPR and EpiPen® training.

Signs and Symptoms

A person experiencing an anaphlyactic reaction might have one of the following symptoms:
F.	Face: rash, itchiness, redness, swelling of face and tongue.
A.	Airway: trouble breathing, swallowing or speaking.
S.	Stomach: stomach pain, vomiting, diarrhea.
T.	Total: hives, rash, itchiness, swelling, weakness, pallor (palenesss) sense of doom, loss of consciousness.

Treatment: Think - A.C.T

Administer the epinephrine auto injector (EpiPen®) IMMEDIATELY, at the first sign of a reaction, in conjunction with the child's contact with their life threatening allergen.

Administer the injection in the lateral (outer) location on the thigh. Inject and count for 10 seconds. Remove the EpiPen®, check needle is showing and massage area for 10 seconds.

A second dose may be administered 10 - 15 minutes or sooner, if symptoms have not improved or worsened.

Call 911. When informing the dispatcher use the term 'ANAPHYLACTIC' reaction.

Transport to hospital by ambulance. Student must go to the hospital even if symptons are mild or have stopped. Call parents/guradians.

Diabetes Hypoglycemia Emergency Action Plan

Classroom Teacher:

Signs and Symptoms

Sweating

divembling

Dizziness

Mood changes

Hunger

Headaches

Blurred vision

Exdiveme tiredness/paleness

Other, please specify:

Optimum Level (Range) of Blood Sugar is:

Location of Sugar Treatment

With Student

Other, please specify:

WHEN IN DOUBT - TREAT

Select one treatment, provided by parent, from the following:

6 oz. (125 ml) of fruit juice/drink (junior juice box) OR

3 - 4 tsp. (10 - 15 ml) of sugar (3 - 4 parckets) OR

6 oz. (125 ml) of regular pop (not diet type) OR

3 - 4 tsp. (10 - 15 ml) of honey OR

4 - 5 glucose tablets OR

Other:

CALL PARENTS TO INFORM THEM

Wait 10 - 15 minutes. If there is no improvement, repeat the above treatment.

DO NOT LEAVE THE STUDENT ALONE!

If the student is unconscious, having a seizure or unable to swallow DO NOT give food or drink.

*Roll the student on his/her side

*Call 9-1-1

*Inform parents/guardians

Submitted by I acknowledge that transportation procedures will apply.

Last Name

First Name

RCJTC ReasonForSpecialTransportation

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

Reason for Special Transportation

Student Photo

Emergency Contacts

Anaphylaxis Emergency Treatment Plan

Student has a potentiall life-threatening allergy (anaphylaxis) to the following:

Signs and Symptoms

Treatment: Think - A.C.T

Diabetes Hypoglycemia Emergency Action Plan

Signs and Symptoms

Optimum Level (Range) of Blood Sugar is:

Location of Sugar Treatment

WHEN IN DOUBT - TREAT

CALL PARENTS TO INFORM THEM

DO NOT LEAVE THE STUDENT ALONE!

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