Over-the-Counter Medication AuthorizationandDietary Restrictions
JJOA Chapter
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Teen's Name
Jack and Jill of America, Far West Region Host Chapter at Teen Conference will have on campus the following non-prescription medications. Please indicate below those which you give your permission for your teen to take as needed. Please sign and date the form. We cannot administer these medications without your signature. Please return this form to your lead chaperone stating your wishes
whether or not
you are giving permission.
Teen's Name
Rows
Yes
No
Comment
Advil (NSAID)
Tylenol (NSAID)
Tums
Ricola cough drops
Benadryl capsules
Benadryl cream
Loratadine (generic for Claritin)
Polysporin ointment
Parent Signature
Print Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Next
Prescription Medication Form
Teen's Name
My child takes no special medications.
My child takes the following special medications:
Name of medication
Purpose of medication
Name and phone of prescribing doctor (if applicable)
To be taken:
as needed
at breakfast
at lunch
at dinner
bedtime
Instructions for use:
Parent Signature
Print Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: