OTC Medication Administration Parent/Guardian Consent

Parental Authorization and Release Form for the Adminsitration of Over-the-Counter Medication

School medications and special health services are adminsitered following these guidelines:
Parent has provideda signed and dated authorization to adminsiter medication and /or provide the health service. Electronic signatures meet the requirements of written signatures.
The medication is in the original, labeled container as dispensed or the manufactrure's labeled container.
The medication label contains the student's name, name of the medication, medication dosage, route to adminsiter, time to adminsiter, and date.
Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.
Over-the-counter medication do not require a prescriber signature and information.

Student Last Name*

Answer required for "Student Last Name"

Student First Name*

Answer required for "Student First Name"

Student Date of Birth*

Answer required for "Student Date of Birth"

My child has the following allergies:*

Answer required for "My child has the following allergies:"

Special Health Services Instructions:

Answer required for "Special Health Services Instructions:"

Parent/Guardian Last Name*

Answer required for "Parent/Guardian Last Name"

Parent/Guardian First Name*

Answer required for "Parent/Guardian First Name"

Parent/Guardian Phone Number*

Answer required for "Parent/Guardian Phone Number"

Please select one*

Answer required for "Please select one"

I GIVE MY CONSENT

I DO NOT CONSENT

Parent/Guardian Signature*

Signature Required

If your child takes a prescription medication, please complete this paper form and return to school nurse:

Please fix the highlighted areas below before submitting.