Student Medical Information

MEDICAL INFORMATION FORM

Student Information

Does applicant have any mental, emotional, physical limitations, or learning disabilities that may affect his/her activities or progress, or for some reason should be known by his/her teachers?

Please specify if your child has any allergies.

Specify if your child requires regular medication to be administered at school. (NOTE: If medication is required on a regular basis, or at a specified time, medication must be brought to the school office, labeled with the child's name and dosage requirements, and a medical permission form must be completed.)

Permission to Receive Medication

By signing this form I understand that Charlotte County Christian Academy is not responsible for any injury or harm that may occur as a result of this medication. Charlotte County Christian Academy reserves the right to revoke this privilege if it is being abused (constant use of pain medication, etc.).*In order to receive pain medication, students must check with their Home Room teacher before coming to the school office for such medication.*

My child will be permitted to be given the following pain medication(s) during school hours if necessary, understanding that this does not mean they are allowed to abuse this privilege. (Please check all allowable ones)

Aspirin (ASA)

Tylenol (Acetaminophen)

Advil (Ibuprophen)

My child is not permitted to receive any pain medications

Parent / Guardian Signature (Note: on Laptop you can use your mouse to sign or on a tablet you can use a stylus or your finger)

IMMUNIZATION RECORD is required for all elementary students enrolling in our school.

Upload File

Emergency Information and Medical Treatment

In case of emergency, and parent cannot be reached, please contact:

Phone

Relationship to Student

I hereby authorize Charlotte County Christian Academy to call an emergency ambulance in case of accident or acute illness, and to arrange for necessary emergency medical aid and surgical care in the case that I, or the designated guardian, am not immediately available. Any qualified physician, called by CCCA, may treat and do whatever is necessary for the health and well-being of my child. It is understood that a conscientious effort must be made to notify me before such action will be taken. I also agree to accept responsibility for the cost of the above medical services.

Parent / Guardian Signature (Note: on Laptop you can use your mouse to sign or on a tablet you can use a stylus or your finger)