Parents, pay particular attention to the
Permission to Dispense Non-Prescription Medications
section of this document.
Make sure to check all medications that you authorize us to give to your child AND
cross out any medications you do not authorize us to give your child. Also, note any allergies your child may have to these medications.
If this part of the form is not filled out, then we will NOT give your child any non-
prescription medications.
It is illegal for students to keep any medication, prescription or non-prescrip-
tion, with them or in their locker. If your child regularly uses any non-prescription
medication, send the medication to the school office in its original container. Like- wise, if your child needs to take a prescription medication, send that medication to the school office in its original container. All medications will be kept and distributed Bethany Christian Schools
Permission for Treatment, Dispensing Medications, and Travel
Student’s name ____________________________________________ Birth date __________________
Address ______________________________________________________________________________ Home phone _________________ Daytime number for parent/guardian _________________________ Emergency contact person ____________________________ Emergency phone __________________ Doctor ___________________________________________ Doctor’s phone ______________________ Date of last tetanus booster ________________ Allergies ____________________________________ Unusual medical problems, if any _________________________________________________________ Medicines being taken by student _________________________________________________________I _______________________________ bearing the relationship of ___________________________ and having legal custody of ______________________________ give the following permissions: Permission for Medical Treatment: I authorize Bethany personnel to consent to any x-ray examination,
anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the student at a recognized medical facility, under the general or special supervision of a licensed physician or surgeon. I un- derstand this is to be used if I cannot be reached so that emergency treatment can be initiated without delay. By this authorization, I indemnify, release, and hold the school harmless from any and all liability in providing care and treatment to my child.
Permission to Dispense Non-Prescription Medications: I authorize Bethany personnel to dispense the
following medications, not to exceed recommended dosage, to this student upon the student’s request and without an attempt to contact me. Check medications authorized and cross out medications not authorized. ____ Acetaminophen (Tylenol, generic equivalent) ____ Ibuprofen (Advil, Motrin, generic equivalent) ____ Antacid tablets (Tums, generic equivalent) It is illegal for students to keep any medication, prescription or non-prescription, with them or in their locker. School policy regarding medications are further outlined in the student handbook.
Permission for Travel: I consent for the student to travel on school-sponsored trips, including those that
involve overnight stays, and hereby voluntarily waive any claim against Bethany Christian Schools, its board of directors and agents/employees for any and all causes which may arise in connection with such trips.
This consent will be valid for the duration of the student’s enrollment at Bethany Christian Schools.
Signer must appear before the Notary.
_________________________________________ _________________________ State of ______________________, County of _______________________On this ____ day of _____________, 20___, ______________________________ appeared before me, ____ whose identity I verified on the basis of ____________________________________________ ____ whose identity I verified on the oath/affirmation of ___________________, a credible witness, to be the signer of the foregoing document, and he/she acknowledge that he/she signed it.
_____________________________________________Notary Public My commission expires: _________________________ 2904 South Main Street, Goshen, IN 46526-5499 phone 574 534-2567 • fax 574 533-0150 • email [email protected]


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