Non-Prescription Medication Authorization Form printable pdf download

NON-PRESCRIPTION MEDICATION

AUTHORIZATION FORM

This form is to be completed and signed by the parent/guardian authorizing medication to be given to the

student during school hours. This form must be completed for non-prescription medications and returned to

the school before the medicine can be given. All non-prescription medication must be in the original container

and labelled with the child’s name. If any changes occur during the school year, a new form must be

completed and returned to school. This form is good for one school year.

Parent Permission Section (to be completed by parent/guardian)

Student ______________________________________________ DOB _______________ Gender _________

Teacher ______________________________________________ Grade _________ School ______________

Parent/Guardian ______________________________________________ Phone _______________________

Emergency Contact ______________________________________________ Phone ____________________

Physician’s Name ______________________________________________ Phone ______________________

The first dose of medication should always be given at home in case of an adverse reaction.

Please check the over-the-counter/non-prescription medication listed below that the school nurse may

administer to your child according to the manufacturer’s recommended dosage. It is understood that the

medication (if available) is administered solely at the request of the parent and as an accommodation. Please

check with the school nurse to see which medications are available for students in the school clinic and which

medications you will need to supply. The school is not able to supply medication for frequent or daily use.

____ Acetaminophen/Tylenol

____ Antacids/Tums

____ Antibiotic/Bacitracin ointment

____ Benadryl/Diphenhydramine ____ Cough drops

____ Hydrocortisone cream 1%

____ Ibuprofen/Motrin

Other Medication: _________________________________________________________________________

________________________________________________________________________________________

Dose ________________________Route ________________________Frequency ______________________

Allergies _________________________________________________________________________________

If given as needed, describe/list indicators: ______________________________________________________

_________________________________________________________________________________________

Possible side effects ________________________________________________________________________

I understand that the Department of Education, its employees or agents shall not incur any liability as a result of any

injury arising from the self-administration of the medication by my child, shall exempt from liability and hold

harmless school employees or agents against any claims arising out of the self-administration of medication by my

child, and I understand that this authorization shall be effective for this current school year and must be renewed

annually.

We are required by law to maintain the privacy of your medical records. This privacy practice is adopted to ensure

that the staff at Maryville City Schools protects your privacy. We consider it our duty to prevent unlawful

disclosure of your medical records. Except as otherwise permitted or required by law, we will not use or disclose

your health records without your written authorization.

Parent/Guardian Signature ________________________________ Date _______________

Non-prescription Medication Authorization Form, Revised March 2015 - 1

Non-Prescription Medication Authorization Form