The horizon christian academy

HORIZON CHRISTIAN ACADEMY
2013 -2014
CONSENT TO ADMINISTER MEDICATION AT SCHOOL
In order for school personnel to administer prescribed or over-the-counter medications such as Tylenol to a student, the following information must be on file and contain the written consent of the parent or guardian. No medication will be given by school personnel without the written consent of a parent or guardian. Student Name __________________________________________________________________________ Date of Birth______________________Grade__________ Daytime Phone__________________________________Emergency Phone________________________________ _____I wish to be contacted BEFORE ANY MEDICATION IS ADMINISTERED TO MY CHILD


Please select and complete info for medications approved to administer to your child.

Topical Creams (poison ivy, anti-itch, etc.) (please include name of medication, dose, etc.) Under NO CIRCUMSTANCES should my child receive the following medications_________________________
Special Instructions and/or conditions we should be aware of. Ex inhaler, heart disease, Epipen, etc. _______________________________________________________________________________________________ Special instructions/storage for Medication____________________________________________________________ Possible side effects and action to be taken if they occur___________________________________________________ ________________________________________________________________________________________________ Physician / Health Care Provider________________________________________Phone________________________ Prescription medication - must be in a clearly marked container from a pharmacist. The label must show the student’s name, the dosage directions, the physician / health care provider’s name and the prescription number. Over-the-counter medication - must be in the original container labeled with the student’s name and dosage directions. No student is permitted to carry or self-administer his or her own medication at school. Medication(s), including prescription and over-the-counter, must be delivered to the office at the start of the school day. Students must arrive at the front desk in a timely fashion to receive their medication. The parent/guardian has the sole responsibility for ensuring that prescriptions are filled or re-filled as needed. This form is valid for the current school year (2013/2014) beginning with the first day of school in August. The undersigned agree not to file or make any claim against anyone for negligence in connection with the administration or non-administration of any medicines and further agree to save such individuals and hold them harmless from any liability incurred as a result of the administration or non-administration of any medicines. I give my permission for the Chief Administrator of Horizon Christian Academy, or his/her designee to administer the prescribed medication. Signature of Parent / Guardian ___________________________________________Date______________

Source: http://www.hcaga.org/wp-content/uploads/2013/07/Student-Medication-Dispensation-Consent-2013-14.pdf