Branch Intermediate School District

Waldron Learning Center

214 Bishop Avenue  Coldwater, Michigan 49036

MEDICAL CARE PLAN FOR STUDENT WITH SEIZURES

Student Name       DOB:      
Parent/Guardian:      
Address       Phone       (Home)       (Work)

Physician (1):      

Physician (2):      
Type of Seizure:      
Receiving Treatment: Yes No
Type of Medication:      
Possible Side Effects:      
Likelihood and Frequency of Seizures During School Hours:      
Any Limitations Specified by the Physician:
Parent/Guardian Comments:      

EMERGENCY PLAN

FOR SCHOOL …
     

DURING TRANSPORT …
     

BUS GARAGE …
     

Parent Signature: ____________________________________ Date:______________________

BISD Nurse Signature: _______________________________ Date: _____________________
Teacher Signature: ___________________________________ Date:______________________
Bus Driver Signature: _________________________________ Date:______________________
Physician Signature: _______________________________________
Date:________________________
S:Linda Bowers/Clinic Forms/Seizure Medical ER Plan