E3 Medical Permissions Form

E3 Academy

Please fill out the Medical Permissions Form below. Ensure all student information and institutional policies are fully reviewed before submitting

Medical Permissions Form

Student Information

Student's Full Name *

Grade *

By submitting this form, I give my permission for any E3 Christian Academy staff member to administer the following medications or medical treatments to my child when deemed necessary. The staff member will record the name of the medication, date, time, and the amount given. This form will be kept on file. Medications will be administered according to pre-stated parental directions or according to medication label. We cannot be responsible for medications that the student takes without the knowledge of the teacher or that are self-administered.

First Aid & Over-the-Counter Approvals

Please check and initial all medications/treatments that you approve for school staff to administer to your child:

First Aid for Cuts, Skin Irritations, Insect Bites & Stings

Alcohol Solutions

Antibiotic Ointment

Benadryl Ointment

Anti-Itch Ointment

First Aid for Minor Pain, Headaches or Allergies

Acetaminophen (Tylenol)

Ibuprofen (Advil or Motrin)

Benadryl (Oral)

Other Approved OTC Medications (Name & Dosage instructions):

Daily Medications & Medical Conditions

Medications Taken Daily or on a Regular Basis (Inhalers, Insulin, etc.)

Name of Medication

Dosage

Reason for Medication

Time Taken

Allergies & Serious Conditions

Allergies to Medications, Foods, or Environmental Factors:

Serious Conditions or Illnesses:

Medication Authorization Sign-Off

Please sign below if the above first aid measures and medications indicated are acceptable. You are giving permission for our staff to administer these medications.

Legal Name *

Name Parent or Guardian *

Date *

Consent for Emergency Treatment

I hereby give my permission to E3 Christian Academy, its teachers, administrators, and staff to request medical treatment for my child in the event of an emergency.

Parent or Guardian Full Name *

Child's Full Name *

Name of Parent or Legal Guardian *

Date Signed *

Physician Contact Information

Doctor's Name *

Clinic Address *

Doctor's Phone Number *

E3 Academy