TEMPORARY CONSENT FOR THE
ADMINISTERING OF MEDICATION
(PARENT COMPLETES TOP PORTION OF
FORM AND BRINGS TO CCS)
I __________________________________ give
permission to _______________________________________
(Name of Parent or Guardian)
Name of Staff)
on staff
at Champion Christian School to
administer ________ of
_________________________________
(Dosage)
(Name of Medication)
to my
child,_____________________________
at approximately _________________________
(Name of
Child)
(Times due and dosage)
on ________________________________ for treatment of
__________________________________.
(Dates - not more than one week)
(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)
Name
of Insurance Company____________________ Policy and/or Group
#__________________