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Over-the-counter medication request form

To be completed by Parent/Guardian

Name of student to receive medication:

Grade*
Answer Required

Please indicate the medications for which you are giving consent to be administered to your child at school. Dosage given will be administered per age and weight instructions on medication container. These medications will be administered on a prn (as needed) basis.

Cough Drops for cough/sore throat
Answer Required
Acetaminophen (generic for Tylenol) for fever or pain
Answer Required
Extra strength Tylenol for fever or pain
Answer Required
Ibuprofen (generic for Motrin or Advil) for fever, pain and/or inflammation
Answer Required
Allergy medication (generic for Benadryl) -antihistamine only- UNEXPECTED ALLERGIC REACTION --RASH, HIVES, SWELLING-- for allergy Symptoms. (Syrup for young children, tablets for older students)
Answer Required
Claritin 10mg or generic Loratadine 10mg tablets for "hay fever-type" allergy symptoms
Answer Required
Sudafed nasal decongestant for runny nose/nasal/head congestion
Answer Required
TUMS chewable for stomach discomfort
Answer Required
Maalox antacid chewable tablets for upset stomach
Answer Required
Imodium AD for diarrhea
Answer Required
Midol for PMS related symptoms
Answer Required
Signature*
Signature Required

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Date:
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