2024-25 Over-the-counter Medicine Authorization Form

1
Your Child's Name
First Name
Last Name
2
Your Child's 2024-25 Grade
Please Select
Please Select
Nitzanim
Ilanot
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
3
Does your child have any food allergies?
YESNO
4
Please list your child's food allergies here:
Huge
Large
Normal
Small
Ok
Ok
5
Describe your child's allergies and reactions in detail:
6
Does your child have allergies to ANY medications?
YESNO
7
Please list the medications to which your child has an allergy:
Huge
Large
Normal
Small
Ok
Ok
8
Describe your child's allergies and reactions in detail:
9
I have read the above over-the-counter medication policy and agree to follow these guidelines. I understand that no medication will be dispensed to my child without written authorization.
10
I authorize the Jewish Community Day School to give my child non-prescription medication. I have provided a labeled container(s) with written instructions to the front office.* This field is required.
Yes
No
11
Student name* This field is required.
First Name
Last Name
12
2024-25 Grade* This field is required.
Nitzanim (3s)
Ilanot (4s)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
13
Name of medication(s)* This field is required.
14
Parent/Guardian name* This field is required.
First Name
Last Name
15
Date* This field is required.
Date
Month
Day
Year
16
Signature
Clear
Should be Empty: