Microsoft word - medical-permission-release.doc

MEDICAL PERMISSION AND RELEASE FORM (Please Print)
CHILD #1____________________________________________________ AGE ________ GRADE _______________________________ CHILD #2____________________________________________________ AGE ________ GRADE _______________________________ CHILD #3____________________________________________________ AGE ________ GRADE ______________________________ CHILD #4____________________________________________________ AGE _________ GRADE _____________________________ Family Physician _______________________________________ Ph # _____________________________________________ Insurance Company ________________________Policy # ____________________ Policy Holder Name __________________ KNOWN ALLERGIES / MEDICAL CONDITIONS
CHILD # 1___________________________________ FOOD PENICILLIN/DRUGS  INSECT STINGS/BITES
PREVIOUS SERIOUS ILLNESSES CURRENT MEDICATIONS  SPECIAL DIET ______________________________
CHILD # 2___________________________________ FOOD PENICILLIN/DRUGS  INSECT STINGS/BITES PREVIOUS SERIOUS ILLNESSES CURRENT MEDICATIONS  SPECIAL DIET ______________________________ CHILD #3 ___________________________________ FOOD PENICILLIN/DRUGS  INSECT STINGS/BITES PREVIOUS SERIOUS ILLNESSES CURRENT MEDICATIONS  SPECIAL DIET ______________________________ CHILD # 4___________________________________ FOOD PENICILLIN/DRUGS  INSECT STINGS/BITES PREVIOUS SERIOUS ILLNESSES CURRENT MEDICATIONS  SPECIAL DIET ______________________________ ************************************************************************************* I HEREBY AUTHORIZE NAPLES CHRISTIAN ACADEMY TO TAKE MY CHILD TO ANY HOSPITAL OR LICENSED PHYSICAN FOR MEDICAL TREATMENT IN THE EVENT OF AN EMERGENCY IN WHICH NEITHER PARENT CAN BE REACHED. _____________________________________________________________________________ Parent/Guardian Printed Name ************************************************************************************* I HEREBY AUTHORIZE ANY LICENSED PHYSICIAN OR MEDICAL TREATMENT CENTER TO TREAT MY CHILD IN CASE OF AN EMERGENCY IN WHICH NEITHER PARENT CAN BE REACHED. _____________________________________________________________________________________ Parent/Guardian Printed Name AUTHORIZATION FOR ADMINISTRATION OF O.T.C. MEDICATIONS
CHILD #1____________________________________________________  Advil/Motrin  Tylenol  Cough Drop CHILD #2____________________________________________________  Advil/Motrin  Tylenol  Cough Drop CHILD #3____________________________________________________  Advil/Motrin  Tylenol  Cough Drop CHILD #4____________________________________________________  Advil/Motrin  Tylenol  Cough Drop Prescription Medication Policy – NOTE - Prescription medication MUST be in the
original container with a label showing the prescribed dosage and name of student. For
insurance liability reasons, students are not permitted to administer their own medications.
Name of Prescription Medication ___________________ Student Name ____________________ Time to be administered  ________ a.m. Time to be administered  ________ p.m.

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