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OCDSB 902 <br />Diabetes Emergency Treatment Protocol Registration <br />(References: P.108.SCO, PR.548.SCO and PR.632.SCO) <br />NOTE: Please type or print neatly and submit the original, signed copy to your child’s school <br />principal in a timely manner. In the case of ongoing serious medical conditions (such as but <br />not limited to severe, life-threatening allergies, diabetes, epilepsy, heart condition, asthma), <br />this authorization will terminate on June 30 of each school year. Please ensure to notify the <br />principal if the prescription changes or expires. This authorization may be cancelled upon <br />receipt of written notification to the principal. <br />School Name: Date: <br />Principal’s Name: Home Form Teacher’s Name: <br />Student’s Name: Student No.: <br />Year/Grade: Pick-up/Drop-off Bus Route Numbers: <br />Location of Treatment Supplies: <br />Transportation Address: <br />STUDENT’S PHOTO: PLEASE ATTACH A RECENT PHOTO OF STUDENT TO FORM <br />SYMPTOMS AND WARNING SIGNS (To be completed by parent/guardian) <br />GENERAL COURSE OF ACTION: <br />Refer to the Individual Diabetes Care Plan (attached) <br />CALL PARENTS/GUARDIANS: <br />Parent/Guardian Name: <br />Parent/Guardian Contact Number(s): <br />OR <br />Parent/Guardian Name: <br />Parent/Guardian Contact Number(s): <br />OR <br />Emergency Contact Name: <br />Emergency Contact Number(s): <br />SPECIFIC COURSE OF ACTION: (To be completed by parent/guardian): <br />PARENT/GUARDIAN AUTHORIZATION RE: CONSENT TO RELEASE <br />I/we give consent for school staff to use and share the information provided in this form as required to <br />attend to the education, health and safety of myself/my child. This may include: <br />The pertinent information contained within will be shared with the Ottawa Student <br />Transportation Authority and applicable contracted bus operators (including your child’s bus <br />driver where appropriate);