Christian academy of louisville ~ rock creek

Christian Academy of Louisville ~ Rock Creek STUDENT NAME________________________________________________GRADE_____________BIRTHDATE_______________________ (Please Print) TEACHER_____________________________________________________STUDENT’S WEIGHT_______________AGE________________ Please list any allergies to medications, foods, insects and/or environmental substances: ________________________________________________ ________________________________________________ Is an Epi Pen indicated for any of these allergies? yes no Please have Epi Pen available in Health Room if indicated.

Please provide any pertinent information concerning medical history, conditions and/or diagnoses and medications taken at home. __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Please initial below any/all over-the-counter (non-prescription) medications that you consent to be given to your child by the Health Room Coordinator, when deemed necessary. All dosages will be based on the student’s weight and age according to package directions. No aspirin or products containing aspirin will be available in the Health Room. Please provide the following information for any prescription or non-prescription (over-the-counter) medications you wish your child to receive in the Health Room. Please bring these medications (clearly marked with students name) with this form to the 1. I,______________________________________, parent/guardian of_____________________________ do hereby request that the Health Room Coordinator of Christian Academy of Louisville administer the above over-the-counter and/or prescription medications to my child when necessary or as directed. I absolve and release the administration and the Board of Education from any claim due to any negative reaction by my child when given the medication listed above in the prescribed dose. PARENT / GUARDIAN__________________________________________________DATE_________________________________ 2. I, _____________________________________, parent/guardian of ______________________________ do not want any over the counter PARENT / GUARDIAN__________________________________________________DATE_________________________________ Please fill in the contact information requested below. Help us find you when we need to talk to you regarding your child. Home phone _________________Mother’s name____________________work #_______________________cell #______________________ Father’s name____________________work #_______________________cell #______________________ Other contact name & relation___________________________________________________home #__________________________________ work #___________________________________________cell #______________________________________________________

Source: http://caschools.us/Websites/caschools/files/Content/3745469/13-14_Medical_Permission_Form_RC.pdf