Preschool Medical Release Form Page 2
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2The following are the approved over-the-counter medications that may be administered at school. Please check yes or
no as to whether your child may be given these medications:
Medication/Dosage
Yes
No
Medication/Dosage
Yes
No
Tylenol/acetaminophen, as directed
Tums, one tablet up to four times a
for weight & age
day
Motrin/Advil/ibuprofen, as directed for
Solarcaine spray for burns, apply as
weight & age
needed
Non-drowsy Robitussin cough syrup,
Triple Antibiotic Ointment, apply as
as directed for weight & age
needed
Cough drops or lozenges, one as
Calamine/Caladryl lotion, apply as
needed
needed
Benadryl for allergic reactions (hives,
Phenylephrine HCL/Non-drowsy
rash, itching, sneezing, runny nose),
Pseudoephedrine free/Nasal
as directed for weight & age
Decongestant tablets/liquid, as
directed for weight & age
Medical Permission for School Health Services
I hereby give permission for my child to receive the following medical attention as part of the state-mandated
regulations and school health program:
Height and weight annually; K – 12
Scoliosis screening examinations; 6 & 7
Vision screening annually; K – 12
Random head lice screening
BMI ratio and BMI percent; K – 12
Puberty informational talk and video; 5
Hearing screening; K, 1, 2, 3, 7, & 11
Each year the school nurse prepares a confidential list that includes students who have significant health
concerns. This confidential list is shared with staff for the sole purpose of protecting the health and well being of
the student. By signing below you allow the nurse to share any information deemed appropriate.
If a parent cannot be notified, and emergency care is necessary, I hereby give my permission for this student to
be transported to the nearest hospital and I give permission for the hospital to give emergency treatment as may
be needed. I will assume responsibility for fees incurred by such an emergency.
Parent’s/Guardian’s Signature: __________________________________________ Date: _______________________
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