High School OTC Medication Authorization

Diocese of Arlington
Appendix F-6A

The Following FOrm must be completed
by Parent/Guardian

High School OTC Medication Authorization: Release and Indemnification Agreement

This form is to be used for clinic stocked over-the-counter (OTC) medications only

Student Name (Last, Middle, First)(Required)

Date of Birth(Required)

Drug Allergies(Required)

School(Required)

School Year (You must fill out a new form each year)(Required)

Occasionally, you child may unexpectedly need medicine during a school day. For those occasions, the school clinic stocks a limited number of over the counter medications which the school nurse may administer with your written permission. The school nurse will assess your child and pertinent comfort measures may be utilized before medication is administered. Only the school nurse or her licensed designee may administer the OTC medications, based on nursing judgment and as instructed on the medication label. Please select the nonprescription medications that the school nurse has permission to administer:(Required)

Ibuprofen 2 (200mg) tablets to reduce inflammations/fever (equivalent to Motrin/Advil)

Acetaminophen 2 (325mg) tablets to reduce pain/fever (equivalent to Tylenol)

TUMS (antacid) for minor upset stomach

Cough drops (cherry flavored/menthol drops)

Parent Signature(Required)

Daytime Phone(Required)