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Ridgefield Academy Acetaminophen/Ibuprofen Authorization Form
In an effort to better serve the health needs of your child, we have developed a policy which allows us to administer acetaminophen and/or ibuprofen to your child if necessary during the course of the school day. In accordance with our medication policy, we are sending you this letter to allow you to give authorization for the School Nurse to administer the medications noted below to your child if necessary for your child’s comfort and safety during the school day.

Please indicate below if you do or do not wish to give the school nurse permission to administer acetaminophen tablet(s) or elixir (generic Tylenol) and/or ibuprofen tablet(s) or elixir (generic Motrin, Advil) to your child for headache, menstrual cramps, orthodontia pain, fever > 101 F. or other pain according to the Standing Orders of the school medical advisor and professional judgment of the school nurse. The Standing Orders allow up to two (2) doses/month of medication for students Pre-Kindergarten through middle school and up to four (4) doses/month of medication for students in the upper school. However, for dosing beyond the Standing Order limit and for all field trips, administration of these medications will require the written order of an authorized prescriber (e.g. your child’s pediatrician) and a parent/guardian’s permission documented on the district’s standard medication authorization form.

Please contact your school nurse if you have any questions.
Your child's information
Please fill in the information below.
Last Name
Your answer
First Name
Your answer
Birthday
MM
/
DD
/
YYYY
Grade
Permission to receive
I give my child permission to receive the following for minor aches, headaches, pain, cramps, and fever higher than 101 degrees:
Acetaminophen (Tylenol)
Ibuprofen (Motrin, Advil)
Additional Notes:
Your answer
In lieu of signature, type in parent/guardian name
Your answer
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