SELF-ADMINISTRATION OF NON-PRESCRIPTION PAIN MEDICATION AUTHORIZATION
A secondary student (grades 7-12) may possess and use nonprescription pain relief in a manner consistent with the labeling, when the school has received a written authorization from the student's parent or guardian permitting the student to self-administer the medication. The school may revoke a student's privilege to possess and use non-prescription pain relievers if the school determines that the student is abusing the privilege. Students may not possess or use any drug or product containing ephedrine or pseudoephedrine.
This form must be completed by the parent/guardian/student and returned to the school health office ANNUALLY.
TO BE COMPLETED BY PARENT/GUARDIAN & STUDENT