OVER THE COUNTER MEDICATION AUTHORIZATION FORM 2024

OVER THE COUNTER MEDICATION AUTHORIZATION FORM 2024
Name of Student (first and last)*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
School: L'Anse Creuse High School North
Grade in 2024-2025*
Over-the-Counter Medication Parent Permission:

As required by state law, please initial each medication you will allow medical staff to administer to your student, per package instructions, as needed.
Tylenol - initial
Ibuprofen (Advil/Motrin) - initial
Pepto Bismol - initial
Benadryl - initial
Neosporin - initial
Hydrocortisone Cream- initial
Ipecac Syrup (for poisoning) - initial
Calamine Lotion - initial
Solarcaine spray (for sunburn)- initial
Sore throat spray/lozenges - initial
I hereby authorize L'Anse Creuse High School North medical personnel or designee the right to administer emergency first aid and/or over the counter medications or generic equivalent included in the list above on the following dates: August 11-16, 2024
Printed Name of Parent/Guardian*
Signature of Parent/Guardian*

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