Classroom Emergency Information (Page 6 of 7) in pdf

Classroom Emergency Information Page 6

Authorization to Dispense External Preparations

590-1-1-.20(1)

Parental Authorization. Except for first aid, personnel shall not dispense prescription or non-prescription

medications to a child without specific written authorization from the child's physician or parent. Such

authorization will include, when applicable, date; full name of the child; name of the medication;

prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and

signature of parent.

I, _______________________________ give The Clifton School staff permission to apply one or

more of the following topical ointments/preparations to my child, __________________________ in

accordance with the directions on the label of the container.

_____ Baby Wipes

_____ Band-aids

_____ Neosporin or similar ointment

_____ Bactine or similar first aid spray

_____ Sunscreen

_____ Insect Repellent

_____ Non-Prescription ointment (such as A & D, Desitin, Vaseline)

_____ Baby Powder

Other (please specify) _________________________________

__________________________________

_________________

Parent/Guardian

Signature Date

Classroom Emergency Information Page 6