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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 for "Grade"

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