MEDICAL TREATMENT

KATY ADVENTIST CHRISTIAN SCHOOL
SCHOOL YEAR
Permission to Administer Medication
Parents: Complete this form and return to the Office with the medication to be given.

I hereby request and grant permission to the Katy Adventist Christian School. to administer medication to my child. If the school administrator / nurse deems it necessary, I also grant the school administrator / nurse permission to notify my child’s teacher(s), either verbally or in writing, of this medication and of possible reactions that might occur. I further state that this medication cannot be scheduled for other than school hours. I understand that oral medication, inhalers, nebulizers and oxygen administration may be given by a medically untrained designate of the principal as per Texas Education Code, Section 22.052.
Student’s Name
Grade
Condition for which medication is to be given

Medications Time for Each Dosage (Non-prescription drugs cannot be given “as needed” except by a doctors order)

	Medication	Dosage	Time for Each Dosage
1
2
3

Special Instructions; if any
Date Requested

Month Day Year
Date
Phone Number
Please enter a valid phone number.
Date of Termination

Month Day Year
Date
Parents Signature

Clear
Email
example@example.com
I wish my child’s medication to be sent on Field Trips.

Yes No
School has my permission to give the AM dose when it is not given at home.

Yes No
I wish to be notified prior to giving the missed dose.

Yes No
I wish my child’s medication to be sent home with him/her on the last day of school

Yes No
PLEASE NOTE THE FOLLOWING MEDICATION POLICIES
1.All medication must be in its original container and be properly labeled. The pharmacy label must state the student’s name, medication, dosage, doctor’s name, and date prescription was filled. The prescription is to be current within the last 12 calendar months. Non-prescription drugs should have the student’s name affixed to the original bottle, and the doctor’s orders. 2.After five (5) consecutive school days, students on non-prescription drugs will be required to submit a physician’s authorization for continuance of medication. 3.Any unused medication left over two weeks after the last dosage will be destroyed. 4. Changes in prescription medications require either a new prescription labeled bottle or written physician request for dosage change. A new parental permission request is to accompany any change in medication. 5.It is requested that medication be brought to the office by the parent and given to the school designated person. No medication will be transported by any school transportation service personnel. 6.Vitamins, minerals, diet supplements, and special diets will not be administered by school staff except from a physician’s written order.
SCHOOL YEAR
Katy Adventist Christian School
CONSENT TO TREATMENT
Only designated staff will have access to the completed form. This form will be stored in a locked file.

This form must be filled out at the beginning of each school year to cover the activities for the school year. A copy of each student’s form must be taken on off-campus activities.
Date of Birth

Month Day Year
Date
Social Security Number
Address
Parent/Guardian’s Name
Father/Guardian Business Telephone
Please enter a valid phone number.
Father/Guardian Home Telephone
Father/Guardian Social Security
Mother/Guardian Business Phone
Please enter a valid phone number.
Mother/Guardian Home Telephone
Mother/Guardian Social Security
Please describe allergies to substances and medication.
If on regular medication, please specify
Date of last tetanus shot

Month Day Year
Date
Physician Name
Physician Office Telephone
Address
2. Family Physician
Office Telephone
Address
Hospital preference
Telephone
Please give the names of two relatives or friends who have consented to assume the responsibility of your son or daughter in case of illness or accident until you can be reached. In case of any changes in the named persons, notify the school in writing.
1. Name
Telephone
Address
2. Name
Telephone
Address
Signature of Parent or Guardian

Clear
Date

Month Day Year
Date
Should be Empty:

KATY ADVENTIST CHRISTIAN SCHOOL

Permission to Administer Medication

PLEASE NOTE THE FOLLOWING MEDICATION POLICIES

Katy Adventist Christian School

CONSENT TO TREATMENT