Fillable Student Medical Permission Form printable pdf download

9998-500455

CCF-455

STUDENT MEDical PErMiSSioN ForM

Rev. 05/10

(Please print or type.)

Student Name: __________________________ Date of Birth: ____ / ____/ ____ Home Phone: ( _____) _______________

Last

First

Address:_____________________________________________________ Sex: ____ Student ID: ___________________

Number & Street

City

State

ZIP

Emergency information

Parents/Guardian Name(s): ________________________________Work Phone: ( ____ ) __________ or ( ____ ) __________

Emergency Contact

: _____________________________Phone Number: ( ____ ) _________

(if parents cannot be reached)

Physician’s Name: _____________________________________________________Phone Number: ( ____ ) _________

Who is responsible for medical payments?

Insurance

Individual

iF iNSUrED, Medical Insurance Company Name: ___________________________ Phone Number: ( ____ ) _________

Insurance Company Address: _________________________________________________________________________

Number & Street

City

State

ZIP

Name of Primary Insured: ______________________________________________ Group #: ______________________

Note: Insurance coverage is not required for participation.

Brief Medical History

Special Health concerns: ___________________________________________________________________________

Asthma:

yes

Heart Problem:

yes

Diabetes:

yes

Allergies:

yes

Seizures:

yes

Other: _______________________________________

(Includes pregnancy, recent surgery,

current Medications:

or other chronic conditions)

Medication:

Dosage per day:

______________________________________________

Note: If your child is taking medication regularly, please bring a supply in a labeled container.

(Please Note: Prescription medication requires a current prescription label. Over-the-counter medication must be

accompanied by an order from a licensed health care provider.)

Should activity be restricted?

yes

If yes, please explain: ________________________________________

_________________________________________________________________________________________________

I, the parent or legal guardian of ______________________________ (my child), authorize and direct the Clark County

School District to obtain medical care for my child in the event such care is reasonably necessary. I understand that, if possible,

I will be contacted in the event my child requires medical attention. I grant to a licensed health care provider or accredited hos-

pital permission to perform any reasonably necessary medical and/or surgical procedures that are essential for the treatment of

my child and agree to be responsible for payment for such care. I release CCSD, its employees, and agents from any damages,

liability, or loss resulting from the exercise of discretion in securing in good faith medical care for my child.

Parent or Guardian Signature: ____________________________________________ Date: _______________________

DIStRIButION OF APPROvED COPIES: 1

Copy/White: advisor, 2

Copy/yellow: Activities Administrator, 3

Copy/Pink: School Nurse

112

Student Medical Permission Form

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