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Parent Permission for the Administration of Over-The-Counter Medication - Grades 4k-5th
Student LAST Name
Student FIRST Name, Middle Initial
Any known food or drug allergies
I give permission for the following medication to be given to my child by designated school personnel: Please check all that apply.
Acetaminophen (Tylenol) Children's Liquid, Dose per Child's Weight
Acetaminophen (Tylenol) Children's Chewable, Dose per Child's Weight
Acetaminophen (Tylenol) Junior Chewable, Dose per Child's Weight
Acetaminophen (Tylenol) 325 mg Tablet, 1 every 4-6 hours
Ibuprofen (Motrin) Children's Liquid, Dose per Child's Weight
Ibuprofen (Motrin) Junior Chewable, Dose per Child's Weight
Ibuprofen (Motrin) 200 mg tablet, 1 every 6 hours
Triple Antibiotic Ointment
Hydrocortisone Cream 1% (Cortaid Itch Relief)
Medication can be given for the following conditions:
Mild Muscular Skeletal Pain
Common Cold Symptoms
Other condition, please specify
THIS ORDER WILL BE IN EFFECT FOR THE CURRENT SCHOOL YEAR.
Parent Signature. By submitting you are signing this Agreement electronically.
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