Agawam Public Schools School Nurse Division -Benjamin Phelps Elementary School

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form is to be filled out by parent or legal guardian for students in Grades Pre-K-5 ONLY

All other medications require a written doctor's order and a written parental permission. Please contact the school nurse for additional information and the proper forms.

Student's Name: *

Grade:
*

PreK

1st

2nd

3rd

4th

5th

I give permission for the School Nurse to administer the following over-the-counter (OTC) medications to my child according to the established protocols. Please select all you give permission to give:

Alcohol Based Hand Sanitizer-As needed to sanitize hands in the absence of soap & water

Aloe Vera Gel-As needed for minor skin irritation, sun burns

Calamine/ Caladryl lotion-As needed for minor skin irritation, itchy rash, insect bites, etc

Cough Drops (will not be allowed for PreK/K)-As needed for minor throat irritation & cough

Saline Solution-As needed to flush eyes or skin wounds

Triple Antibiotic Ointment-As needed for cuts, scrapes, etc

Vitamin A & D Ointment / Vaseline-As need to promote healing of minor skin irritations

Required

I attest that, to the best of my knowledge, my child has no allergy/sensitivity to any of the above named products.
*

Yes

Signature

Please type in your name in the field below. Each party agrees that this Agreement and any other documents to be delivered in connection herewith may be electronically signed, and that any electronic signatures appearing on this Agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Agawam Public Schools. Report Abuse

Forms