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Limestone Walters OTC (over-the-counter) Medication Authorization Form.  
This form is for OTC medications that are commonly given out during the school day.   Please mark yes or no stating whether or not you would like your student to receive medications listed below during the school day.  Note that most of the medications do need to be supplied by the student in its original container.  School nurse will contact the primary care provider to receive physician signature for each medication marked "yes".

If student is requesting Tylenol or Ibuprofen in the morning, a phone call will be made to caregiver to verify that student has not already taken a form of this medication prior to coming to school.

This form is optional.  Students should take OTC medications at home when possible. 

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Email *
Student First and Last Name *
Primary Care Provider Name and Phone Number  *
Student Allergies *
TYLENOL   (Student must provide) *
Required
IBUPROFEN     (Student must provide) *
Required
TUMS     (Student must provide) *
Required
COUGH DROPS     (Student must provide) *
Required
CORTISONE CREAM     (School will provide) *
Required
Must agree to the following in order for RN to administer medication as needed at school *
Required
By typing my name below, I am agreeing to allow school nurse to administer the medication(s) above marked "yes" during school hours.  I understand that school nurse will contact my student's primary care provider to obtain physician signature.  I will receive an e-mail from school nurse if my student receives any of the marked "yes" medications during school hours.  *
A copy of your responses will be emailed to the address you provided.
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