LWA Over the Counter Medication Consent
The following is a list of over the counter medications that can be administered during school. Your child WILL NOT be given any of these medications without consent via this form. Parents will be notified when medications are administered, with the EXCEPTION of antacid tablets, cough suppressant drops, petroleum jelly, Blistex, triple antibiotic ointment, saline solution, saline eye wash, oral analgesic and anti-itch lotion.
Please check the medication(s) that your child may receive while at school.
Ibuprofen 200mg (age 12 and over) - as directed on label for pain or temperature
Ibuprofen Junior (Motrin) under age 12 - as directed by age and weight for pain or temperature
Ibuprofen Children's age 2-11 - as directed by age and weight for pain or temperature
Acetaminophen (Tylenol) 500mg (age 12 and over) - as directed on label for pain or temperature
Acetaminophen Junior (Tylenol) under age 12 - as directed by age and weight for pain or temperature
Acetaminophen Children's, age 2-11 - as directed by age and weight for pain or temperature control
Diphenhydramine Hydrochloride 25 mg (generic Benedryl) - as directed on label for allergic reactions/allergies
Triple Anti-biotic Ointment - as directed on label to promote healing and prevent infection of minor cuts and abrasions
Anti-itch Lotion - as directed on label for temporary relief of pain/itching due to poison ivy, oak, or sumac, rash, and insect bites
Saline Eye Wash - as directed on label for removal of foreign objects and air pollutants from the eye
Contact Saline Solution - as directed on label for rinsing contacts
Cough Suppressant Drops - as directed on label for temporary relief of coughs and sore throat pain
Oral Analgesic - as directed on label for tooth pain
Petroleum Jelly or Blistex - for chapped lips
I give permission for the school Health Clerk and office personnel to administer the above-checked over the counter medications to my child as needed.
Parent/Guardian Full Name
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