Form Ccf-455 - Student Medical Permission Form - Ccsd Clark County School District Page 2

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q 
My child requires medication or a health procedure during the field trip.
Medications must be in an appropriately labeled bottle from the pharmacy and less than 1 year old.
Over the counter medications require a prescription from a Licensed Health Care Provider and must be in the
original container. The prescription must include student’s name, dose, time, and indication for use.
Licensed Health Care Provider orders and CCF 643 Parent/Guardian Permission Form are required.
q 
FOR SECONDARY STUDENTS ONLY: My child is able to self-administer his/her medication (except for controlled
substances) during the field trip.
Medications must be in an appropriately labeled bottle with a written statement that the student may carry and
self-administer the medication.
The following medications/procedures are required:
_____________________________________________________________________________________________________________
Medication
Dose
Time(s)
_____________________________________________________________________________________________________________
Medication
Dose
Time(s)
_____________________________________________________________________________________________________________
Medication
Dose
Time(s)
_____________________________________________________________________________________________________________
Health Procedure (Licensed Health Care Provider orders required)
Time(s)
If medical information/needs change during the school year, please contact the school nurse.
I, the parent or legal guardian of ______________________________ (my child), authorize and direct the Clark County
School District (CCSD) 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 hospital 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/Guardian Print
Parent/Guardian Signature
Date
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