OTC Medication Electronic Form ( + Health Update)

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This parent request form will allow the school nurse to give your child some basic OTC medicines during the 2023-2024 school year (as needed) at school. It is optional. This consent form will only be good for one school year. Our school doctor, Dr. Tronetti has approved medications and prescribed the appropriate dose per weight.

Please note that Mrs. Bickford, certified school nurse will be on maternity leave at the beginning of the school year. A long term substitute nurse will be in her place caring for students in the health office until mid November.

Email *

What is your STUDENT'S last name? *

What is your STUDENT'S first name? *

What grade is your student in for the 2023-2024 school year? *

I give permission for my child to take ibuprofen during the 2023-2024 school year. *

Yes

I give permission for my child to take acetaminophen (Tylenol) during the 2023-2024 school year. *

Yes

I give permission for my child to take Benedryl for allergic reaction for the 2023-2024 school year.

* Please note that Benedryl will never be provided for daily allergy concerns.

Yes

I give permission for my child to take cough drops during the 2023-2024 school year. *

Yes

I give permission for my child to take tums during the 2023-2024 school year. *

Yes

I give permission for my child to use throat spray (for a sore throat) during the 2023-2024 school year. *

Yes

I give permission for my child to use bacitracin ointment (substitute like neosporin). *

Yes

Are there any NEW or EXISTING health conditions you would like the school nurse to be aware of?

Does your child take any daily medications? *

Yes

If you answered yes to the previous question, please list medications and dosages of current medication being taken by your child:

If your child requires medications to be given in school that are a part our standing order agreement, you will need orders from your child's doctor for them to be given in school. If you have questions, please reach out to Mrs. Bickford, school nurse.

Does your child have any allergies? *

Yes

If your student has allergies, what is your student allergic to?

Check all that apply:

My child has asthma

My child has been prescribed an inhaler by their doctor

My child has been prescribed an epi-pen

Please select your child's doctor's office: *

If you selected "other" on the question listed above, please specify your doctor's name or your doctor's office name below.

Who is your student's dentist? If you do not have one please state that below. *

Please type your name below if you are the parent/guardian completing this form. *

Confirmation *

I have read and reviewed all my responses and confirm that I am the parent/guardian of the student listed above. I understand that this form is only good for the 2022-2023 school year.

Required

A copy of your responses will be emailed to the address you provided.

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