Non-Prescription Medication Authorization Form

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NON-PRESCRIPTION MEDICATION
AUTHORIZATION FORM
This form is to be completed and signed by the parent/guardian authorizing medication to be given to the
student during school hours. This form must be completed for non-prescription medications and returned to
the school before the medicine can be given. All non-prescription medication must be in the original container
and labelled with the child’s name. If any changes occur during the school year, a new form must be
completed and returned to school. This form is good for one school year.
Parent Permission Section (to be completed by parent/guardian)
Student ______________________________________________ DOB _______________ Gender _________
Teacher ______________________________________________ Grade _________ School ______________
Parent/Guardian ______________________________________________ Phone _______________________
Emergency Contact ______________________________________________ Phone ____________________
Physician’s Name ______________________________________________ Phone ______________________
The first dose of medication should always be given at home in case of an adverse reaction.
Please check the over-the-counter/non-prescription medication listed below that the school nurse may
administer to your child according to the manufacturer’s recommended dosage. It is understood that the
medication (if available) is administered solely at the request of the parent and as an accommodation. Please
check with the school nurse to see which medications are available for students in the school clinic and which
medications you will need to supply. The school is not able to supply medication for frequent or daily use.
____ Acetaminophen/Tylenol
____ Antacids/Tums
____ Antibiotic/Bacitracin ointment
____ Benadryl/Diphenhydramine ____ Cough drops
____ Hydrocortisone cream 1%
____ Ibuprofen/Motrin
Other Medication: _________________________________________________________________________
________________________________________________________________________________________
Dose ________________________Route ________________________Frequency ______________________
Allergies _________________________________________________________________________________
If given as needed, describe/list indicators: ______________________________________________________
_________________________________________________________________________________________
Possible side effects ________________________________________________________________________
I understand that the Department of Education, its employees or agents shall not incur any liability as a result of any
injury arising from the self-administration of the medication by my child, shall exempt from liability and hold
harmless school employees or agents against any claims arising out of the self-administration of medication by my
child, and I understand that this authorization shall be effective for this current school year and must be renewed
annually.
We are required by law to maintain the privacy of your medical records. This privacy practice is adopted to ensure
that the staff at Maryville City Schools protects your privacy. We consider it our duty to prevent unlawful
disclosure of your medical records. Except as otherwise permitted or required by law, we will not use or disclose
your health records without your written authorization.
Parent/Guardian Signature ________________________________ Date _______________
Non-prescription Medication Authorization Form, Revised March 2015 - 1

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