2023-2024 OTC Medication Permission

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The Health Office will have the following over-the-counter medication available to give to
students according to written protocol and with written parent/guardian permission. Please check
which medications your child(ren) may receive for minor health problems such as a cold,
menstrual cramps, headache, sore throat, muscles, backache, eye irritations, burns, sprains, upper
respiratory infections, upset stomach and rashes.

Please complete this form for each student you are enrolling.

Email *

Student Name *

Grade *

Choose one option: *

May give all medications listed below

DO NOT GIVE ANY MEDICATION

Give ONLY medications checked below

Checks medications allowed:

Acetaminophen, age appropriate dose (PROVIDED BY YOU)

Ibuprofen, age appropriate dose (PROVIDED BY YOU)

Tums, (500mg Calcium tab), age appropriate dose

Triple Antibiotic Cream

Hydrogen Peroxide (wound cleanser)

Hydrocortisone Cream 1%

Cough Drops (PROVIDED BY YOU!)

Calamine Lotion

Caladryl Clear

Aloe Vera Sunburn Relief

Opti-Clear Eye Drops

Contact Lens Solution

I understand that my child can receive medications through School Health Services. I understand that this is dispensed at the discretion of the school health personnel. I understand that medication brought to school must be in the original container with all the information current to what the child receives. I understand that the authorization of medication form must be signed for prescription medications. I understand no phone permission will be accepted. Parent/Guardian- Please "Sign" and date in the box provided. *

Send me a copy of my responses.

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