TEMPORARY CONSENT FOR THE ADMINISTERING OF MEDICATION

(PARENT COMPLETES TOP PORTION OF FORM AND BRINGS TO CCS.)

            I, , give permission to , on staff

                  (Name of Parent or Guardian)                                            (Name of Staff)

                    at Champion Christian School to administer of                                                                                                                            (Dosage)

                                            to my child, , at approximately

      (Name of Medication)                                                         (Name of Child)

                                               on for the

      (Times due and dosage)                                     (Dates - not more than one week)

treatment of .

                                (Reason for Necessity of Medication)

/

                                                   (Signature of Parent)                  (Date)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

(STAFF MEMBER IS RESPONSIBLE TO SEE THAT THE FOLLOWING CRITERIA HAVE BEEN MET)

            1          Top half of form has been completed                                                 YES NO

            2          Medicine is contained in a safety type container                                 YES NO

            3          An original prescription label is on medication                                    YES NO

                         a)         Name of child on label                                                           YES NO

                         b)         Date of prescription on label                                                  DATE

                         c)         Instructions on label consistent with

                                      top half of this form                                                                YES NO

            4          Name of prescribing physician:

            5          Telephone number of prescribing physician:

/

(Signature of Staff) (Date)082099

Name of Insurance Company____________________ Policy and/or Group #__________________