Permission to Treat

Permission to Treat
Student Name*

First NameLast Name
Student's DOB

MonthDayYear
Date
Parent or Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
I hereby give permission to the medical personnel selected by the school administrator of Faith Christian Academy to provide routine health care; to administer medications; treatment; to release any records necessary for insurance purposes: and to provide or arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the school administrator to secure and administer treatment, including hospitalization, for the student named above.

Permission to Administer Over-the-Counter Medications:

I hereby give permission for Faith Christian Academy to administer the following over-the-counter medications if the nurse deems it necessary. Dosages will be administered according to the directions on the bottle unless a physician directs otherwise.

Headache | Tylenol | Upset Stomach | Pepto Bismol | Diarrhea

Imodium AD | Menstrual Cramps | Ibuprofen | Poison Ivy | Calamine Lotion or CortAid
I agree with the above statements.*

YES
Parent or Guardian Signature*

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