2025-2026 Enrollment Form

Cincinnati College Preparatory Academy Single Student Application

CCPA is proud to offer a Free Public Education to all enrolled students

Our mission is to holistically guide and direct students in the development of personal character and academic potential through top-quality teaching and child-centered programs in a safe, positive and caring environment.

We appreciate your interest in the Cincinnati College Preparatory Academy. Thank you for your thorough review of the school admission application and policies.

Important Application Policies For Your Review – Parent /Guardian Initial Required.

Child Find Policy: The school supports and complies with all applicable federal and state laws, procedures, and policies regarding the school’s child find responsibilities. The school will conduct child find activities and follow all state and federal policies.  ________ Parent/Guardian Initial

HB410 – Attendance/Truancy: Did you know?  A student is chronically absent if he or she misses as few as 2 days of a school month. It is important for every student in Ohio to attend school every day. Missing too much school has long-term negative effects on students, such as slower achievement and graduation rate. Under the new definitions outlined in H.B. 410, the designation of “Habitual Truant” is defined as any child of compulsory school age who has been absent without legitimate excuse for: 30 or more consecutive hours, 42 or more hours in a school month or 72 or more hours in a year.________ Parent/Guardian Initial

Automatic Withdraw: Once a student has not participated in 72 consecutive hours of instruction, CCPA is obligated to automatically withdraw the student and notify the student’s resident district. 

________ Parent/Guardian Initial

State Testing Requirements: "The Cincinnati College Preparatory Academy is a community school established under Chapter 3314. of the Revised Code. The school is a public school and students enrolled in and attending the school are required to take proficiency tests and other examinations prescribed by law. In addition, there may be other requirements for students at the school that are prescribed by law. Students who have been excused from the compulsory attendance law for the purpose of home education as defined by the Administrative Code shall no longer be excused for that purpose upon their enrollment in a community school. For more information about this matter contact the school administration or the Ohio Department of Education." ________ Parent/Guardian Initial

Special Education: Does your child require Special Education Services or do you think your child may need Special Education Services?  For more information on Special Education please refer to A Parent’s Guide to Special Education on page 7 in this packet. ________ Parent/Guardian Initial

McKinney Vento:

Children and youth experiencing homelessness face unique challenges in accessing and succeeding in school. Certain documentation may not be required if the student applicant qualifies under the McKinney-Vento Act. Please refer to pages 5 and 6 for more information and complete all questions in the application packet for determination.

________ Parent/Guardian Initial

Please see the school website at www.ccpaonline.com under the drop down policies tab for important admission policies for your review. For complete listings of all policies related to students, see the easily accessible handbook on the website in which you may view or download. If you cannot access the CCPA website you may contact the school office at 513-684-0777 and a hardcopy will be printed for you.

School Admission at a glance…

        Step 1: This application is completed (for important school information)

        Step 2: Placement Exam

        Step 3: Lottery- all positions will be filled per grade level by a lottery drawing.  

Enrollment is not guaranteed.

For ALL Kindergarten Applicants: If your child was born AFTER AUGUST 31st  the application will not be considered unless applicant passes the early KG admittance test. Early KG Testing is available at the expense of the parent. ________ Parent/Guardian Initial

Step 1: A COMPLETE APPLICATION SHOULD BE ACCOMPANIED BY:

___ Student Birth Certificate                 ___ Proof of Guardian ship (if not the birth parent/s)        

___ Student SS Card                        ___ 1 Valid Proof of Address (See POA Requirements page)

___ Current Report Card/Transcripts        ___ Copy of Parent / Guardian Drivers’ License or State ID

___ CURRENT Immunization Record        ___ Copy of current ETR and IEP (if applicable)         

___ PLACEMENT EXAM (Exam Date/Time: _____________________________  ___:____  am / pm)

___ STUDENT FEES ($25 MUST BE PAID AT TIME OF ENROLLMENT)

McKinney Vento - TEMPORARY LIVING ARRANGEMENTS

Children and youth experiencing homelessness face unique challenges in accessing and succeeding in school. The following questions address the McKinney-Vento Act 42. U.S.C. Certain documentation may not be required if the student applicant qualifies under the McKinney-Vento Act.

Answers to these questions will help determine what services a student may be eligible to receive.

Is student’s current address a temporary living arrangement   □ Yes        □  No

If Yes, is this temporary living arrangement due to the loss of housing or economic hardship   □ Yes        □  No

Please pay special attention to pages 5 & 6, and request a meeting with the School Liasion.                                                                

Step 2: SCHOOL NURSE – MEDICAL FORMS VERIFICATION – 

ALL Medical Forms must be completed. 

A Physician’s signature is required for the Prescription and Non Prescription Medication Forms. The School nurse must verify completed documentation prior to student attending school.

__ Health History  __ Immunization Record __ Physical Form  __ ER Med Authorization

__ Prescription and Non-Prescription Medication Forms

Student Background Information

Last Name____________________________ First Name: _____________________Middle ________________                   Entering Grade Level _________                Gender (Check one)      □      Male          □        Female

Home Address: ______________________________________  Apt. # __________

City _________________ St ________ Zip______    

House Phone or Parent/Guardian Cell #: _____________________________  Unlisted: □ Yes        □  No

Student Cell #: _________________________  

Student E-mail address: ___________________________________@_______________________

Race/Ethnic Code (Please check all that apply) □ Black/African American     □  White/Caucasian  □ Multi-Racial       □ Hispanic/Latino  □  Asian □ Native Hawaiian/Other Pacific Islander      □  American Indian/Alaskan Native

Student’s Birthdate: ________________________________  (month/date/year)  

Student’s Birthplace: City: ___________________________   State: ______ Country: ______________

Student’s Social Security Number: ________-_______-_________

Reason for Enrollment (Please check all that apply) □ From out of state/country     □ from home school in Ohio

□ From an Ohio Public/Charter (community school)    □  Not in Ohio Public/Charter schools since 2003

□ First time in Ohio public school due to age      □  Not newly enrolled in this district

List the name of the most recent Pre-K  or School attended:  ____________________________________________

How did you hear about CCPA? ____________________________________________________________

STUDENTS WITH SPECIAL NEEDS – Provide documents where needed.

Does child require mobility assistance?                                                 □ Yes        □  No

Has child ever had an ETR (Education Team Report)?                                         □ Yes        □  No

If Yes, is there an evaluation form available?                                                 □ Yes        □  No

Did the child receive Special Education and related services in most recent school?                □ Yes        □  No

Does this child have an IEP (Individualized Education Program)?                                  □ Yes        □  No

If Yes, which disability or special need exists? _________________________________________

Does this child have a 504 Accommodation Plan?                                         □ Yes        □  No

If Yes, is there an 504 form available?                                                         □ Yes        □  No

Did child receive Gifted services in most recent school?                                         □ Yes        □  No

If Yes, is there a WEP or WAP (Written Education Plan; Written Acceleration Plan) Available?         □ Yes        □  No

STUDENT TRANSPORTATION

Will your elementary student be in need of transportation via Yellow Bus?     □ Yes    □ No

If NO what will be the means of transportation?   □ Walker         □ Parent Pick-up   (If PPU, please ask Pick My Kid App)

High School students will receive Metro Bus Cards.

Family and Emergency Contact Information

Mother/Guardian: _____________________________________________________________________      

Home Number: _____________________________   Cell Phone _____________________________

Work Phone: __________________________      Other: ________________________________

Address: ________________________________________ City _________________ St _____ Zip______

Social Security Number: ________-_______-_____

Email:__________________________________________________

Would you like to receive text messages regarding school events, school closings etc? □ Yes        □  No

Are you an active duty member of the Military?  □ Yes        □  No

If Yes, which branch? □ Army  □  Air Force □ Navy □  Marines □ Coast Guard  □  Reserves

Father/Guardian: _______________________________________________________________________          

Home Number: _____________________________   Cell Phone _____________________________

Work Phone: __________________________      Other: ________________________________

Address: ________________________________________ City _________________ St _____ Zip______

Social Security Number: ________-_______-________        

Email:_________________________________________________

Would you like to receive text messages regarding school events, school closings etc? □ Yes        □  No

Are you an active duty member of the Military?  Are you an active duty member of the Military?  □ Yes        □  No

If Yes, which branch? □ Army  □  Air Force □ Navy □  Marines □ Coast Guard  □  Reserves

        In case of Emergency or if the school is unable to contact myself please contact the following 

  ______________________________________      _________________     _________

   Name                                                                 Relationship to Child                     Telephone

  ______________________________________       ___________________________    

   Address                                                            City/State/Zip           

  ______________________________________      _________________     _________

   Name                                                                 Relationship to Child                     Telephone

  ______________________________________       ___________________________    

   Address                                                            City/State/Zip        

  ______________________________________      _________________     _________

   Name                                                                 Relationship to Child                     Telephone

  ______________________________________       ___________________________    

   Address                                                            City/State/Zip         

LIST ANY ADDITIONAL CONTACTS HERE:

  ______________________________________      _________________     _________

   Name                                                                 Relationship to Child                     Telephone

  ______________________________________       ___________________________    

   Address                                                            City/State/Zip        

  ______________________________________      _________________     _________

   Name                                                                 Relationship to Child                     Telephone

  ______________________________________       ___________________________    

   Address                                                            City/State/Zip        

  ______________________________________      _________________     _________

   Name                                                                 Relationship to Child                     Telephone

  ______________________________________       ___________________________    

   Address                                                            City/State/Zip        

I understand that it is my responsibility to notify CCPA of any changes that may occur

involving these contact people and phone numbers AS WELL AS my personal contact

information.

Parent/Guardian Signature                                                         Date

I understand that according to House Bill 21 that the school will require a current, to

date proof of residency on an annual basis.  The annual proof of residency should be

submitted no later than September 1 of each school year or upon request of school

administration.

Parent/Guardian Signature                                                         Date

                   McKinney-Vento Act Residency and Educational Rights

(Questionnaire must be completed for each student)

In the state of Ohio in 2016 over 355,000 individuals were found to be homeless of these individuals 4,113 were under the age of 18. The McKinney-Vento Homeless Assistance Act was created with the goal of ensuring the enrollment, attendance, and success of homeless children and youth in school.

The McKinney-Vento Act provides certain rights for homeless students. This includes waiving certain requirements such as proof of residency when students are enrolling and allowing eligibility for certain services, such as free textbooks, school meals, etc.

McKinney-Vento Residency Form

Please complete this form and return it with this enrollment packet. Questions may be directed to your Principal, Social Worker, or Andrea Cope, Director of Student Services/McKinney-Vento Liaison, 513-684-0777 Susannah Wayland , McKinney-Vento State Coordinator, 614-387-7725

Student Name: ____________________________    Date of Birth: ___/___/___   Grade: ____

The McKinney-Vento Homeless Assistance Act (Title X, Part C, of the No Child Left Behind Act) defines “homeless” as “individuals who lack a fixed, regular, and adequate nighttime residence.” This includes children who “are temporarily sharing the housing of other persons due to the loss of housing or economic hardship.”

              Does not apply; student is not homeless

Please check one of the following statements if your family is experiencing temporary homelessness:

Living in a shelter, including transitional housing shelters (i.e. City Gospel Mission, Cornerstone, Haven House, Lighthouse); awaiting foster care, etc.– Please provide name and address of shelter:                                                                                                                         

Living on the streets, abandoned buildings, in cars, trailers, campgrounds, public places, housing not fit for habitation--Please provide information regarding area in which student is living:

______________________________________________________________________________________

Living in hotels/motels for lack of other suitable housing. Please list name and address of hotel/motel:

______________________________________________________________________________________

Doubled-up; temporarily living with family or friends due to lack of adequate housing or financial conditions. Please provide address of where student is living: Address: _______________________________________________________________________________

Please answer the following if you check one of the four boxes above:

How long do you expect to be at this address? ___________________________________________________________

Are you seeking permanent housing?           Date student moved to this address:  ____________ 

Is a parent living in the home with the student?          __________________________________________

If no, with whom is student living?        Relationship: _______________________

The School Homeless Liaison may be in contact with you if clarification or bus transportation is needed.

We have read the information provided and indicated our living circumstances above with regard to the McKinney-Vento Act:

_____________________________________________________                 ____________________

Signature of Parent/Guardian/Unaccompanied Youth                                               Date

If you are a parent of a child who has a disability that interferes with his or her education, or if your child is suspected of having such a disability, this basic guide will serve as a valuable resource for your child’s education.

WHAT HAPPENS IF MY CHILD IS HAVING TROUBLE LEARNING IN SCHOOL?

The Individuals with Disabilities Education Improvement Act of 2004, the federal law commonly referred to as IDEA, has established a process for determining your child’s educational needs,     determining whether or not your child has a disability, and obtaining special education services, if your child’s disability requires them. Here is that process, in roughly the order it will be carried out:

Request for assistance—This step helps you begin a relationship with your school district so that together you can address any early warning signs that your child may have difficulty in school.

Request for evaluation—School districts have qualified personnel who have a lot of experience determining how well children learn and function in school. Because of this, they can bring valuable resources to the task of assessing your child.

Evaluation—This is the step that allows the school district to pinpoint whether your child has a disability that will require special education services (not all disabilities do). The evaluation will suggest what kinds of special education services your child will need or confirm that your child will be able to learn in a general education classroom with other students. You will be a partner in the evaluation process and a member of your child’s evaluation team.

Development of an individualized education program (IEP)—If the evaluation reveals that your child has a disability that requires special education, this customized program will be designed to set goals for your child’s learning and keep your child on track.

Annual review—Each year the public school district will review with you and the IEP team how well your child’s IEP is working and will be prepared to adjust the plan to ensure that your child is making appropriate progress.

Reevaluation—The IDEA law provides for your child to be evaluated again every three years to detect any important changes in his or her ability to learn. This “reevaluation” also tells you and the school district whether the supports and services your child is receiving are the right ones. The school district can then act accordingly.

Independent educational evaluation (IEE)—If you do not agree that the school district’s evaluation of your child is accurate, you can arrange an evaluation of your child by a qualified professional or professionals who are not employed by the school district. In certain cases, this can be done at the school district’s expense.

You may obtain a copy of A Guide to Parent Rights in Special Education From the school office or visit our website at ccpaonline.com.

You may also review the entire guide by visiting

http://education.ohio.gov/getattachment/Topics/Special-Education/ODE_ParentRights_040617.pdf.aspx

Parent Consent Form

I hereby give consent for the following children to receive all of the below stated services and grant permission for all of the below item:

□        My child may participate in activities or field trips that involve being transported or walking within a 1 mile radius of the school grounds and/or are routine field trips scheduled such as trips to the following: park, children’s theatre, library, union terminal, art museums, YMCA swimming pool, Cincinnati recreation center, Cincinnati Zoo, Newport on the Levee, and others as needed upon the discretion of the principal.

□        I grant permission for my child to have photos taken to be used for media publications upon the discretion of the school superintendent or designee.

□        I give my permission for the principal or his/her designee to administer prescribed medication or treatment.

□        I give my permission for my children to participate in the school based health program i.e. seeing the doctor or nurse practitioner for any health needs while at school or involved in a school supported event.

□        In the event medical attempts have been unsuccessful, I hereby give consent for 911 to transfer the child to any hospital reasonably accessible if the administration of any treatment deemed necessary by school based health physicians or designated practitioners is not available or successful.

□        I understand The Cincinnati College Preparatory Academy is a community school established under

Chapter 3314. Of the Revised Code. The school is a public school and students enrolled in and

attending the school are required to take proficiency tests and other examinations prescribed by law.

In addition, there may be other requirements for students at the school that are prescribed by law.

Students who have been excused from the compulsory attendance law for the purpose of home

education as defined by the Administrative Code shall no longer be excused for that purpose upon

their enrollment in a community school. For more information about this matter contact the school

administration or the Ohio Department of Education.

Parent Signature: ______________________________________________ Date: ________________

PLEASE READ CAREFULLY

By signing this application, I certify under oath that the information given in and attached to this application is true, complete and correct. I understand that falsifying information on this application could result in the loss of enrollment for my student.

Parent Signature: ______________________________________________ Date: ________________

CINCINNATI COLLEGE PREPARATORY ACADEMY

DISTRICT IRN 133512

Release of Student Records

Student Information:

Student Name: _____________________________  Grade: _____ Birthdate:_______________

Parent Signature: ____________________________________   Date: ___________________

Please release all appropriate past and present academic, discipline, medical, confidential and special education records (including psychological information, diagnostic summaries, IEP, etc.) on the student named above.

Records should be sent to the school address as indicated.

Cincinnati College Preparatory Academy                        

Attn: Student Records

1425 Linn Street                                                

Cincinnati, OH 45214

Phone: 513-684-0777        Fax: 513-684-8888

Name and Address of School releasing records:

__________________________________________                Phone: ________________________

__________________________________________                Fax: __________________________

__________________________________________

CCPA USE ONLY:

STUDENT INFO FOR REVIEW ONLY ___________

STUDENT HAS ENROLLED AS OF:_____________

TO BE COMPLETED BY PREVIOUS OHIO SCHOOL DISTRICT

OR OUT OF STATE SCHOOL

ENROLLMENT/WITHDRAWAL INFORMATION

Student Name:________________________   Grade: ______ Date of Enrollment: ___________

Student SSID# _____________________________________

School District Name: ______________________________________________________

District IRN#: _________________________________

School Name: _____________________________________________________________

Last day the student attended your district: __________________________

Expulsion Information: Please advise if this student has been expelled from your school, reason for expulsion and dates:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 

DENIAL OF RECORDS RELEASE

If you CANNOT release cumulative school report cards/transcripts, we would appreciate the return of this sheet with the following information provided. We will relay it to the parent/guardian. Thank you for your assistance.

Cumulative School Records for the above named student CANNOT be released for the following reason(s):

_____Fees Due  (Amount owed $________)       _____  Books not returned  ______Grades Incomplete

______ No records available        _____ Other: ______________________________________________

_____________________________________________________________________________________

__________                ________________________________

Date                        Signature/Title of Sender

RETURN TO:  CINCINNATI COLLEGE PREPARATORY ACADEMY

               1425 LINN STREET

                CINCINNATI, OHIO 45214

                FAX: 513-684-8888

Proof of Address/Residency

 Requirements

Upon your student being awarded an enrollment position, 1 current proof of residency will be required for all new enrollees and when change of address occurs. Residency shall be established by providing an original or copy of one (1) item from List A or from List B.

LIST B ITEMS: Proof of residency must show a visible month, day and year and must be current within previous 30 days, and must be addressed to the parent at their residence.

ALL DOCUMENTATION MUST BE IN THE STUDENT’S FILE BEFORE ENROLLMENT CAN BE COMPLETED.

ENROLLMENT AND TRANSPORTATION COULD BE AFFECTED IF PROPER DOCUMENTATION IS NOT SUBMITTED.

A current Proof of Residency will be requested on a yearly basis to satisfy the requirements of the student data updates.

Students/Families qualified under the McKinney Vento Act will be omitted from this requirement.

CINCINNATI COLLEGE PREPARATORY ACADEMY

HEALTH HISTORY FORM

This form is required by Ohio State law.  Please complete, sign and return to the school office as soon as possible.

CHILD’S NAME_________________________________________        DOB________________

1.  Is your child allergic to any medications?         □ Yes   □  No

If Yes, please list: ________________________________________________________________________

2.  Any food allergies?  (Please list)    

_______________________________________________________________________________________

Any other allergies? (Latex, Environmental, Insect Bites/ Stings) (Please list)  

_______________________________________________________________________________________

3.  Does your child have any of these problems?  (Please circle Yes or No)

Please list any other health problems or illnesses: ____________________________________________

Does your child see a physician/physician specialist for any items you checked above? □ Yes   □  No

 If yes please list::________________________________________________________________________

HEALTH HISTORY FORM, continued

4.  Does your child CURRENTLY take any medications? □ Yes   □  No

If Yes, name of medication(s):_______________________________________________________

_______________________________________________________________________________

5.  Has your child had any operations, serious injuries or hospitalizations? Yes____ No____

Explain:________________________________________________________________________

_______________________________________________________________________________

6.  Specifically, has your child had any heart surgery?                    Yes______ No______

Explain:______________________________________________________________________

7.    Does your child have any dental problems and/or toothaches?           Yes_____     No_____

8.    Is your child on any special diet or have special dietary needs?   Yes_____    No_____  

  Explain:________________________________________________________________________

9.  Is there anything else related to your child’s health, physically, mentally and/or emotionally that we (the school health staff) should know about?

_______________________________________________________________________________

_______________________________________________________________________________

Do you have any concerns you want the school health care provider to address during this school year?

_______________________________________________________________________________

_______________________________________________________________________________

NOTE TO SCHOOL NURSE: Students with Food Allergies must be reported to the School Food and Nutrition Department.

  CCPA PHYSICAL EXAMINATION FORM 2023 - 2024

TO BE COMPLETED BY A PHYSICIAN

           Student Name: ______________________________ Examination Date: _________

           Date of Birth: _______  Weight:___  Height:___   Head Size:___  Blood Pressure:___    

           Normal ___ Abnormal ____

           Problems or Abnormalities: (ie.. Speech, Communication)    

           _____________________________________________________________________

            Development:  ___   Normal   ___ Abnormal    Comments: ______________________

            Hearing – Type of Test: _______________        Vision - Type of Test: _________

            Date: ______________________                        Date: ____________________

            Results: ___   Normal   ___ Abnormal                  Results: ___   Normal   ___ Abnormal    

            Comments: ________________________           Comments: ____________________

            Allergies: _____________________________________________________________

            Medications: __________________________________________________________

            Restrictions: __________________________________________________________ 

        Based upon an examination consistent with Cincinnati College Preparatory Academy this child is in suitable condition for enrollment.       

            Physician Name: ______________________________________________

           Physician Address: _________________________________Phone: _______________

           Physician Signature/Stamp: ________________________________________________

Emergency Medical Authorization 2023-2024

Student Name _________________________  Grade______DOB ________________   Purpose – To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school  authority, when parents or guardians cannot be reached.

Residential Parent or Guardian:

______________________________        Relationship to student: ________________

Parent or Guardian Name (please print)                        

Home Number (______)_______________ Cell  Number  (______)________________

Work Number  (______)________________        

Address: ___________________________   City/State/Zip: _______________________

Part 1: TO GRANT CONSENT.  I hereby give consent for the following medical care providers and local hospitals to be called.

Physician: ____________________________________                Phone: _______________________

Dentist:     ____________________________________                Phone: _______________________

Medical Specialist: ____________________________                Phone: _______________________

Local Hospital: _______________________________                Phone: _______________________

In the event reasonable attempts have been unsuccessful, I hereby give consent for 911 the administration of any treatment deemed necessary by above-named doctors, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist, concurring in the necessity for surgery, are obtained prior to the performance of such surgery.

Facts concerning the child’s medical history, including allergies, medications being taken and any physical impairment to which a physician should be alerted: 

_______________________________________________________________________________________

Date: _____________  Signature of Parent/Guardian: ____________________________

Part II: REFUSAL TO GRANT CONSENT.  I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring treatment, I wish the school to take the following action:

_______________________________________________________________________________________

Date: ________________  Signature of Parent/Guardian: ____________________________________

Dispensing Non- Prescription Medications

at School 2023-2024

A registered nurse is on duty part time to provide emergency and supplemental care for students. Students often have minor ailments and complaints that prohibit maximum effort in school, but can be eased, with simple over the counter remedies. The nurse may also use alternate methods of care (ice packs, rest) when possible.

We require written permission annually from you and your physician for each child, if our nurse is to give intermittent non-prescription remedies. Students who routinely use certain medications are encouraged to provide their own non-prescription medicine. This medicine will be kept in the Health and Wellness Office.

___ YES, I hereby grant permission for the school nurse to dispense only those over the counter medications, which are checked below. I release the nurse and school personnel from any liability for the administration of said preparations.

Student Name ______________________________  Grade______    DOB _________________    

________________________________________        ________________________      ________

Parent/Guardian Signature                                               Telephone Number                          Date  

Physician, Please complete the medications you permit:

List any drug allergies: _________________________________________________________________

_____________________________________________________________________________________

List all routine OTC medications:_________________________________________________________

_____________________________________________________________________________________

Dispensing Prescription Medications at School 2023-2024

Student Name: __________________________ Grade: ________  DOB: ____________

Address: _________________________________ Apt # ________   Phone: __________

City: ______________________________ State: __________ Zip Code: _____________

TO BE COMPLETED BY THE STUDENT’S PHYSICIAN:

Name of Medication(s): ________________________________________________________________

Dosage: ___________________________ Duration of Dosage:_____________________

How Administered: _______________________________________________________________________

Possible Side Effects: _______________________________________________________________________

_______________________________________________________________________

Physician Name: ______________________________________________

Physician Address: _________________________________Phone: _______________

Physician Signature/Stamp: ________________________________________________

TO BE COMPLETED BY THE PARENT:

The undersigned agree not to file or make any claim against anyone for the negligence in connection with the administration or non-administration of any medications and further agree to save such individuals and hold them harmless from liability incurred as a result of the administration or non-administration of any medications.

I give my permission for the Principal or his/her designee to administer the prescribed medication.

Date:____________  Signature of Parent/Guardian: ______________________________

Address: ____________________________________ City/State/Zip: ___________________________

1425 Linn Street, Cincinnati, OH 45214   I 513.684.0777   I www.ccpaonline.com