Parent Authorization For Administration Of Acetaminophen, Ibuprofen Or Naproxen At School Form printable pdf download

Parent Authorization For Administration Of Acetaminophen, Ibuprofen Or Naproxen At School Form

PRINCE GEORGE COUNTY PUBLIC SCHOOLS

P ar e nt Aut hor i zat i on f or Admi ni s t r at i on of

Ac e t am i nophe n, I bupr of e n or Napr oxe n at Sc hool

(A s e par at e f or m mus t be c ompl e t e d f or e ach me di c at i on.)

P ARENT/ GU AR DI A N SEC TI O N

Student _______________________________________________________ DOB______________________________

Medication Allergies _______________________________________________________________________________

List of Child’s Medical Conditions ____________________________________________________________________

I, ____________________________________________, parent or legal guardian of above student, request that the

principal’s designee at _________________________________ School administer the below medication to my child.

In signing this form, I am agreeing to hold the school and its personnel free from any legal action that might arise from

this arrangement.

I also understand that I am to abide by the school division regulations as stated below:

It is my child’s responsibility to come to the clinic to take his/her medication.

•

Parent or guardian must bring medication into school office or clinic. Medication cannot be transported on buses or by

•

students.

Medication must be in the original, unopened container, labeled with student’s name.

•

The first dose of a new medication should be given at home.

•

Any changes in medication require a new written authorization.

•

If a child requires medication for 3 or more consecutive school days, parent or guardian will be required to provide written

•

authorization from a licensed prescriber.

Parent or guardian must provide medications/equipment required to administer medications or provide special medical care.

•

Left over medication must be picked up at the end of the school year or it will be discarded.

•

Medication (as it appears on bottle): ___________________________________________________________________

Amount or Dosage to be Administered: ________________________________________________________________

Time or Frequency to be Administered: ________________________________________________________________

Reason for Medication: _____________________________________________________________________________

Duration or Length of Time to be Administered: _________________________________________________________

Parent/Guardian Signature ______________________________________________ Date _______________________

Parent/Guardian PRINTED Name _____________________________________________________________________

Home Phone ______________________ Work Phone _____________________ Cell Phone _____________________

HSM 0008-0809

Parent Authorization For Administration Of Acetaminophen, Ibuprofen Or Naproxen At School Form