OTC Parent Medication Form

BARNEVELD SCHOOL DISTRICT
Robyn Oberfoell District Administrator

Heather Schmitz Principal

Melanie Norton Dean of Sutdents

Hilary Shemak School Nurse
Parent(s)/Guardian Medication Authorization Form

Over the counter medications - As needed meds
Student's First & Last Name*
Date of birth*

MonthDayYear
Date
Address*
Grade*
As the parent and guardian of the above-mentioned student. I give the Barneveld School District permission to administer the following medication(s)to my child for the following reason or diagnosis*

Rows	Medication/Dosage (mg, CC, ml, etc)	How it is to be given	How Often	Start Date	Stop Date	Considerations/side effects
1.
2.
3.

All meds must be furnished by the parent and is to be in the original bottle. Do not send pills in baggies or envelopes.

As the parent or guardian of the above-mentioned student, I will keep the school district aware of any changes in medication(s) profile or health concern of my child. As a part of the Wisconsin Statute Chapter 118.29. Administration of Drug to Pupils and Emergency Care, school districts are required to have permission from a medical provider and parent to administrator medications at school. As part of this authorization form. school district employees may contact the medical provider with questions regarding the medication administration including clarification regarding dosage, side effects or indication of the medication(s) listed above with parent permission.
Parent(s) Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

BARNEVELD SCHOOL DISTRICT