Form Ccf-455 - Student Medical Permission Form - Ccsd Clark County School District
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29998-500455
CCF-455
STUDENT MEDICAL PERMISSION FORM
Rev. 02/17
New form must be completed for each trip
(Please print or type)
Student Name: ______________________________________________ Sex: _______ Date of Birth: ________________
Last
First
MI
Student ID: _______________________ Address: _________________________________________________________
Number & Street
City
State
ZIP
Home Phone: ( _____ ) _____________ School: ________________________________ Teacher: __________________
Field Trip Destination: ________________________________________ Date(s) of Trip: __________________________
Emergency Information
Parents/Guardian Name(s): ________________________________________________________________________________
Cell/Work/Home Phone: ( _____ ) _______________________________ or ( _____ ) ________________________________
Emergency Contact
(if parents cannot be reached)
: ___________________ Phone Number: ( _____ ) _________________
Physician’s Name: ___________________________________________ Phone Number: ( _____ ) _________________
Medical and Prescription Information
q
q
Does your student have any health conditions?
Yes
No
If yes, please describe: _______________________
______________________________________________________________________________________________________
q
q
Will your child be attending a field trip that extends beyond regular school hours?
No
Yes
If your child requires medication or a health procedure that is not administered at school, the health office will need appropriate
paperwork and Licensed Health Care Provider (LHCP) orders at least ten days prior to the trip. For questions, concerns, or to
obtain the required forms, please contact your child’s school health office.
Please check the appropriate box below:
q
My child does not require any medication on the field trip.
q
My child requires an inhaler or Epi-pen.
•
Licensed Health Care Provider Orders and CCF 643 Parent/Guardian Permission Form are required.
•
Per NRS 392.425, permission is required from your Licensed Health Care Provider for your student to carry and
self-administer these medications. (Obtain this form HS-96 in the Health Office)
q
My child requires diabetic care during the field trip.
•
Extended care orders are required for care outside of the school day.
•
Licensed Health Care Provider orders and CCF 643 Parent/Guardian Permission Form are required.
DISTRIBUTION OF APPROVED COPIES: 1
Copy/White: advisor, 2
Copy/Yellow: Activities Administrator, 3
Copy/Pink: School Nurse
st
nd
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