Medical Permissions/Consent Form

Medical Permissions/Consent Form
Student's Name:

First NameLast Name
Grade
Date

MonthDayYear
Date
By signing this form I give my permission for any Strickland School staff member to administer the following medications or medical treatments to my child when deemed necessary. The staff member will record the name of the medication, date, time, and the amount given. This form will be kept on file. Medications will be administered according to pre-stated parental directions or according to medication label. We cannot be responsible for medications that the student takes without the knowledge of the teacher or that are self-administered.
Please check all medications that you will approve on the lines provided.
First aid for cuts, skin irritations, insect bites and stings:
Alcohol solutionsAntibiotic ointmentBenadryl ointmentAnti-itch ointment
First aid for minor pain, headaches or allergies:
Acetaminophen (Tylenol)Ibuprofen (Advil or Motrin)BenadrylOther
Medications that my child takes daily or on a regular basis (inhalers, insulin, etc.):
Name of medication:
Dosage:
Reason for medication:
Time Taken:
Allergies to medications:
Serious Conditions or Illnesses:
Please sign below if the above first aid measures and medications indicated are acceptable. You are giving permission for our staff to administer these medications.
Signature of parent or guardian:

Clear
Date:

MonthDayYear
Date
CONSENT FOR EMERGENCY TREATMENTFOR STUDENTS
I, the parent or guardian of hereby give my permission to Strickland Christian School, its teachers, administrators and staff to request medical treatment for the above named child in the event of an emergency. Printed name:
Signature

Clear
Date

MonthDayYear
Date
Doctor's Name
Address
Phone
Format: (000) 000-0000.
Revised 2/02/2026
Should be Empty:

Medical Permissions/Consent Form

CONSENT FOR EMERGENCY TREATMENTFOR STUDENTS