Robinson CUSD #2 Student Medication Consent

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Please complete the following form for each of your students in the district.

Email *

Student's Last Name *

Student's First Name *

Student's date of birth *

YYYY

Student's School *

Washington Grade School

Lincoln Elementary School

Nuttall Middle School

Robinson High School

Student's Grade Level *

I consent for the School Health Professionals of Robinson CUSD #2 to treat my child if deemed necessary or advisable based on his/her presentation to the School Nurse Office. It is recognized that minor symptoms occur that may not be relieved through comfort care. The School Health Professional does have certain over-the-counter medications in stock which can be administered if authorized by the parent on this form. Before granting school permission to administer over-the-counter medication, please check with your doctor/pharmacist that the medications below do not interact with any medications your child may already be taking.

Acetaminophen (Tylenol)

Ibuprofen (Motrin/Advil)

Benadryl antihistamine (for generalized allergic reaction)

Artificial tear solution

Hydrocortisone cream/Caladryl (topical itching/rash)

Tums/antacid/Pepto

Cough Drops (menthol, i.e. Halls)

Triple antibiotic ointment

Oragel/Campho-phenique

Sunscreen/Aloe

No, my child may not be given any over-the-counter medications or options listed. I understand that only comfort care measures (such as an ice pack/rest) will be administered until I am contacted.

Yes, my child may see the School Health Professional and receive the over-the-counter medications indicated if deemed appropriate based on his/her presentation and symptoms. I have checked with his/her physician/pharmacist to verify the safety with other medication.

Does your student have any allergies? If yes, please list below with reaction. *

Does your student have any health conditions? If yes, please list below. *

Does your student take any routine medications? If yes, please list below and provide medication authorization form from your child's physician to the school nurse if medication needs to be administered at school. *

Parent/Guardian Signature

*By signing below you are verifying you are the parent/guardian of this student and are responsible for providing the correct health and medication information and consent choice requested above.

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