Fillable Long Term Non-Prescription Medication Request Form printable pdf download

Long Term Non-Prescription Medication Request Form

Download a blank fillable Long Term Non-Prescription Medication Request Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Long Term Non-Prescription Medication Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Print Form

Reset Form

-P

ONG

ERM

RESCRIPTION

EDICATION

EQUEST

): _____________________________ A

:______ G

: _______ S

I.D. # ________________

TUDENT

AME

RINTED

RADE

CHOOL

Allergies (Medication): _________________________________________________________________________________

As parent/guardian of the above named student, I request the School District to give medicine for the following condition(s) (Check all that apply)

Headache

Cramps

Dental

Other: _______________________________________________

ONDITION

Acetaminophen

Ibuprofen

Naproxen

Midol/Premsyn/Pamprin

Other _____________________________

EDICINE

Dose: ___________________ Frequency: _____________________ Specify Time: _________________ or As Needed: ___________________

I understand that the school is not legally obligated to administer medication to my child. Therefore, I agree to defend and hold harmless, the school district and

its employees from any liability for the results of the medication or the manner in which it is administered, and to defend and indemnify the school district and

its employees for any liability arising out of these arrangements. Medication request must be deemed necessary to maintain or improve health and participation

in the school program. Each request will be assessed for the most appropriate intervention and will be given at the standard dosage recommended by

manufacturer. I will notify the nurse if I give this medication to my child before arrival at school while this request is in effect to prevent overmedicating. I agree

to supply medication for my student in its original packaging (small bottles only, please). I also affirm that my child has taken this medicine at least two times in

the past without any adverse side effects. I understand that the medicine will be destroyed unless picked up by the end of the last student school day of this

year. Medicines will not be kept by the school over the summer break per DEA regulations.

_________________

Parent/Legal Guardian Signature: __________________________ Printed Parent Name: _____________________ Date:

VER THE

OUNTER

EDICATION

DMINISTRATION

ECORD