Tipton Academy

Student Name: _____________________________________________
□ Yes, my child has Medical Condition □ No, my child does not have a Medical Condition
List Medical Condition in detail: 
Please attach any relative information regarding the Medical Condition(s)                If Medication is needed during school hours, you may pick up a Medical Permission form at the office.
□ Yes, my child has Allergies □ No, my child does not have Allergies
List Allergies in detail:
I Do Not Hold Tipton Academy responsible for forgetting to administer medication to my child.
Parent/Guardian’s Signature: ______________________________ Date: __________ If I want to ensure that my child receives the medication, I have the right to come into the school and administer this medication to my child.