Over-the-Counter Medication Consent Form

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Parent/Guardian Consent for over-the-counter (OTC) medication is required to be completed and presented to the student's school before any medication may be administered to a student during the school day. **ALL medications need to be provided by the parents/guardians. Medications cannot be expired. The schools do NOT have stocked medications.**

Email *

Record my email address with my response

Last Name of Student *

First Name of Student *

Student Date of Birth *

YYYY

School building my student attends: *

Humke Elementary

Alexander Middle School

Nekoosa High School

All medications must be in their ORIGINAL CONTAINER listing ingredients and dosage recommendations.

I grant permission to the persons designated by the principal to give medication(s) to my child according to the directions.

I authorize school personnel to exchange information with my child’s clinician regarding this medication or the condition for which it is prescribed or written.

I release the school district from any liability claims of the administration of this medication as directed.

I will notify the school in writing of any changes.

Non-prescription dosing may not exceed package recommended dosing without a clinician written order. Prescription medication changes require a new clinician order.

I consent to all of the above

I give my student permission to transport OTC medication to and from school, and will not hold the school liable for any accident, injury, or loss of medication that may occur during transport.
*

Yes

No, a parent/guardian will bring all OTC medications to school to be dispensed in the office.

Name of Over-the-Counter Medication (please submit separate form for multiple medications):
*

Acetaminophen (also known as Tylenol)

Ibuprofen (also known as Advil or Motrin)

Cough Drops

Naproxen (also known as Aleve or Naprosyn)

Tums

Other:

Dose & Frequency for Selected OTC medication
*

As written on the bottle provided. Circle one every 4hrs every 6hr every 8hrs

As written and submitted by your student's medical provider (MD, DO, NP, PA). Orders may be faxed to the student's school office.

My child may take this OTC medication at school without authorized school personnel dispensing the medication. *

Yes, the student will administer their own OTC medication to self only. My student is aware they are unable to administer medication to other students.

No, the school office personnel and/or school nurse will administer the student's OTC medication.

Duration of OTC medication administration *

For the entire school year (starts on 1st day of school & ends on last day of summer school)

For 5 consecutive days (any longer would require new authorization)

I understand all medication must be picked up at the end of the school year or it will be destroyed. *

I consent.

By typing my name below, I am acknowledging and giving my approval. *

Phone Number of legal parent/guardian giving consent *

Relationship to Student *

Legal Parent

Legal Guardian

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