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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