Parent Permission and Request to Administer Non-Prescription Pain Relivers 2023-24

Parent Permission and Request to Administer Non-Prescription Pain Relievers 2023-24

This form needs to be updated annually. Please complete a separate form for each child.
- This signed form is required for the school to administer medication when the student’s health requires it.
- Students will not be allowed to self-administer medications.
- Non-prescription pain relievers are not supplied by the school.
  - Parents must supply all properly-labeled medication in its original container, with the student’s name and grade clearly marked.
  - Medications will be kept in a locked cabinet in the health room and be administered by the school nurse or supervised designee. Upon termination of the pain relief administration, any unused medication will be returned to the parent named in this form.
- Minnesota State Law (M.S. 126.201) requires medications which are administered at school must be in a container or prescription bottle properly labeled by a pharmacist or physician.
NON-PRESCRIPTION PAIN RELIEVERS:
IBUPROFEN (such as Advil), ACETAMINOPHEN (such as Tylenol)
Student Name*

First NameLast Name
Student/Participant 1 Grade for 2023-24*
The Above-Named Student is to Receive
NAME/BRAND/TYPE OF MEDICATION
Dosage Instructions
EXACT DOSAGE
Time(s) of Day
TIMING OF MEDICATION
For the Treatment of
REASON NEEDED
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Possible Side Effects Include
POSSIBLE SIDE EFFECTS
Unused Medication Should be

Returned to the parent via the student named in this formHeld at the office for the parent to pick upOther
If necessary, please add further information regarding non-prescription pain relievers
Parent/Guardian Signature:
I hereby authorize the school nurse or designated school personnel to administer the above medication.

YesOther
Sign and date (if this electronic signature doesn't work for you, please print and sign the hard copy and return to the school office)

Clear
Full name used in the signature above *
Today's Date

MonthDayYear
Parent Email*
example@example.com
Should be Empty:

Parent Permission and Request to Administer Non-Prescription Pain Relievers 2023-24