Permission for Over-The-Counter and Prescription Medications (In-School and Trips Administration)
This form is required for ALL students and must be submitted annually. Both Parent/Guardian and Physician Signature are required.
Student Name:
*
Grade:
*
Check here if you DO NOT approve ANY OTC medications to be given by the school nurses or designees
I DO NOT approve ANY OTC medications to be given by the school nurses or designees
Permission For School Nurse To Administer Non-Prescription Medications
Rows
Check to indicate permission.
All medications on the list below
Acetaminophen(Tylenol) liquid/pill
Diphenhydramine(Benadryl) liquid/pill
Tums tablet
Loratidine (Claritin)pill
Certirizine (Zyrtec)liquid/pill
Hydrocortisone cream
Ibuprofen (Motrin/Advil)liquid/pill
Opcon A allergy eye drops
Vaseline/Aquaphor
Saline/Refresh eye drops
Bacitracin antibiotic ointment
Cough drops (6 years & older only)
Lubriderm fragrance-free skin lotion
Prescription Medication
I permit the school nurse or designee to administer the below medications to my child at school or on a school trip:
Rows
Medication
Dosage
Route
Time
Taken at school
1
Yes
No
Occasionally
2
Yes
No
Occasionally
3
Yes
No
Occasionally
Parent/Guardian name:
*
Parent/Guardian signature:
*
Date signed by parent/guardian:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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Submit
Should be Empty: