Microsoft word - wchs enrollment front page.doc

Clark-Pleasant Community School Corporation
Permission to Administer Medication and First Aid to Student
School Year: 2009-10
This form is valid for one school year and must be renewed yearly.
Student Name
Home Phone Grade
Student health alerts, medical
conditions, or allergies:

I am the parent/guardian of the above-named child whose date of birth is / / . I am acting on my
own behalf and on the behalf of this minor child. I understand that by the operation of the law, specifically
Indiana Code 34-30-14-2, a Clark-Pleasant Community School Corporation employee or staff member
administering medication in accord with this permission statement shall be immune for all liability for acts
arising of the administration of medication in accord with the terms of this document, except in the case of gross
negligence or willful and wanton misconduct. Therefore, I hereby authorize and agree to hold the Clark-Pleasant
Community School Corporation and its officers and employees harmless for the administration of:
ΠTylenol (Acetaminophen) or Advil (Ibuprofen): a non-prescription pain/fever reducer medication, to be
administered according to the manufacturer’s recommended dosage. This will only be dispensed on an as-
needed basis at the discretion of the nurse (up to 6 times a semester). If your child has frequent headaches or
a frequent need for pain relievers, you will need to bring their medication in its original container
accompanied with a completed “permission to administer medication” form to the school. A child is only
allowed to carry emergency medication in school and only with a physician’s note, in accordance with
Indiana Code.
ΠAntacid: a non-prescription medication to be administered in a dosage of 1 or 2 tablets for relief of acid
ΠBenadryl (Diphenhydramine Hydrochloride): a non-prescription antihistamine for allergy relief, dispensed
with verbal consent from the parent or guardian for allergic reactions as defined in the Indiana State Department of Education’s “Guidelines for Emergency Care of Injuries and Illnesses Occurring at School.” By signing below, you verify that your child is not allergic to Diphenhydramine Hydrochloride and give the school permission to administer it in an emergency when you are unreachable by phone. It will be administered according to the manufacturer’s recommended dosage. In addition, a school nurse or other school staff member designated by the school’s nurse may provide first aid according to the “Guidelines for Emergency Care of Injuries and Illnesses Occurring at School.” Unless indicated on this form that your child is allergic to these items, first aid treatment may include the local application of such medicines as: Œ Bacitracin antibiotic ointment
ΠMedi-Quick first aid antiseptic and pain relieving spray (applied to minor superficial scrapes and lacerations
ΠEye Wash irrigation solution (used to flush the eye if a foreign object is suspected or eyes are irritated from
ΠCaladryl Clear external analgesic and itch-relief lotion (applied to insect bites or itchy skin)
By signing below, you verify that your child is not allergic to any above-mentioned non-prescription medication and give the school permission to administer them when needed. The above-referenced medications will be administered according to the manufacturer’s recommended dosage. Parent/Guardian Signature
Date of Signature
Parent/Guardian Printed Name
Daytime Phone

Source: http://www.cpcsc.k12.in.us/WCHS/PDF/med.pdf