Gospel Outreach Christian School
2800 West Cullom, Chicago, Illinois, 60618-1558                               Phone:773.604.4147   FAX:  773.604-5124
                                                                                                                K-12 college preparatory
                                                                                                                urban ministry since 1981
                                                                                                                nondenominational
 
 

Request for Student  Medication Administration
(Nonprescription and Prescription )

School Year _______
Student’s Name _____________________        Birthdate __________      Grade _______
Parent’s Name_____________________          Home Phone__________  Daytime phone________
Emergency contact _______________


Please list any medical conditions or allergies which your child has:

Prescription Medication to be administered______________________________
Dosage to be administered_____________________________ Time or interval ___________________

Permission request to administer non-aspirin when a headache or fever of 100 degrees or above occurs:
__Yes;  __No    Dosage: ___________________   Parent’s Initials _______
(Top section to be completed by parent or guardian)


Physician Statement of Need for Continuing Prescription Administration:
To the Physician :   The parents of the student above have requested Gospel Outreach School to administer the prescription medicine stated above during school hours.  Please complete the following information and fax back to the school at (773) 604-5124  Attn:  Administrator .

Does the prescription medication above have a generic name also______________________________________
List of severe reactions that should be reported to physician____________________________________
Special instructions for storage of medication_____________________________________________
Special instructions for  administration of medication _______________________________________
Date to begin administration __________________     Date to cease administration ________________

Should the administration of this prescription medication be reviewed by the physician regularly? ___Yes;  ___No    If yes, how often _________________________

Physician’s Name _________________________  Physician’s Signature____________________
Physician’s Address ______________________________  Physician’s Phone Number _____________________ Physician’s Fax No. _________________________Emergency contact information for physician______________


Parent’s Authorization:
I request that Gospel Outreach Christian School administer the above medication to my child in accordance with my request and the physician’s  statement of need ( if a prescription medicine).  I agree to notify the school in writing of any changes in my child’s condition with respect to the administration of medication or with any changes to the information provided on this form.  I understand that it is my responsibility to send an appropriate supply of medication to school in its original container.  Medication provided to the school in any container other than the original will not be administered.    I understand that the school will have limited liability while administering medication to my child in accordance with a Physician’s Statement of Need or my Request for Medication Administration.  The school agrees to keep a written log of medication administered to my child in school throughout the current school year.   Further, I understand that the school will obtain appropriate medical care in the event of an emergency.   I (We) the parent(s), will be financially responsible as the school does not provide student medical insurance.  I (We) may choose to purchase student accident coverage, when offered.

Parent’s Signature  ____________________________________          Date  ____________

You shall love the Lord your God with all your heart, and with all your soul, and with all your mind.  Matthew 22:37

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