Medical Release Form
Complete this form for each student attending CLPS.
*Please provide any current LABELED prescription medications, Epi-Pens, or inhalers to the front office.
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Email *
Student Last Name *
Student First Name *
Date of Birth *
MM
/
DD
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Current Grade *
OVER-THE-COUNTER MEDICINE PERMSISSION
The following medications can be given to my child: *
Yes
No
Please call first
Ibuprofen (Advil)
Acetaminophen (Tylenol)
Benadryl
Zyrtec
Claritin
Cough Syrup/Tablets
Cough Drops
Pepto-Bismol
Tums
Eye Drops (Visine)
Anti-Itch Spray/Cream
Neosporin
ALLERGIES
Enter NONE for any response that is not applicable.
Please list any allergies (food, medication, other): *
Please explain reaction, current treatment, and medication for allergies. *
ASTHMA
Please explain current treatment and medication. *
OTHER CHRONIC CONDITIONS
Please list any other chronic conditions that the school needs to be aware of: *
Please explain current treatment and medication. *
Please explain any limitations or activities the student should not be engaged in *
DOCTOR INFORMATION
Primary Care Doctor Name *
Primary Care Doctor Phone Number *
I give my child permission to participate in the Christian Life Preparatory School (a) electives or extracurricular activities, and (b) to ride as a passenger in any vehicle and with any driver authorized by the school’s administration to provide student transportation for purposes directly related to that same activity. I also give CLPS authorized representatives (staff sponsors or chaperones) permission to seek emergency medical assistance for my child as may be deemed necessary and appropriate. Finally, I recognize that the school and its representatives bear responsibility for my child’s well-being only when he or she is under their direct authority and only to the extent that my child accepts and cooperates with their leadership and direction.
 *
Required
Sign Name *
Date *
MM
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DD
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