Geneseo Schools

4:110E

Student Name:

Student Date of Birth:

Parent/Guardians Name:

Parent/Guardians Email Address:

Home Phone:

Cell Phone:

School:

Grade:

Teacher:

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 requires medication for: (describe conditions and circumstances)

Medication information, including dosage, directions and where kept:

Sign and Submit

I agree that I am the person whose name is listed below.

Parent/Guardian Name:

Note: You will recieve an email confirming your request after you

' . PHP_EOL . 'Reply-To: Webserver ' . PHP_EOL . 'X-Mailer: PHP/' . phpversion(); $message1 = (("Emergency Medical Information for Students Who Ride School Buses"."\n"."\n").("Date: $dateadded"."\n"."\n").("Student's Name: $Student_Name"."\n"."\n").("Student Birth Date: $Student_Date_of_Birth"."\n"."\n").("Parent/Guardian's Name: $Parent_Guardian_Name"."\n"."\n").("Parent/Guardian's Email Address: $Applicant_Email"."\n"."\n").("Home Phone: $Home_Phone"."\n"."\n").("Cell Phone: $Cell_Phone"."\n"."\n").("School: $School"."\n"."\n").("Grade: $Grade"."\n"."\n").("Teacher: $Teacher"."\n"."\n").("Physician's Name: $Physician_Name"."\n"."\n").("Physician's Phone: $Physician_Phone"."\n"."\n").("School Nurse's Phone: $School_Nurse_Phone"."\n"."\n").("Child's Special Needs are: $Special_Needs"."\n"."\n").("Child requires medication for: $Child_Requires_Medication_For"."\n"."\n").("Medication information - dosage - directions: $Medication_Info_Dosage"."\n"."\n")); $email_message2 = mysql_real_escape_string($message1); $message = $message1; if ($Student_Name != '') { $mail = mail($to, $subject, $message1, $headers); $mail2 = mail($Applicant_Email, $subject2, $message1, $headers); $insertemaildatabase2 = mysql_query("INSERT INTO `dist228`.`emergencybus` (dateadded, email_message) VALUES ('$dateadded', '$email_message2')"); if ($mail == 'TRUE') { print 'Your request has been sent

'; } else { ?> Sorry, you did not fill out all the fields. Please try again.