General Over-the-Counter medication parental consent form. (Form #3)
This form provides consent for the School Nurse to administer the following over-the-counter medications, if needed, to your child during the senior Disney trip
Sign in to Google to save your progress. Learn more
Email *
LAST NAME of Student attending the trip, as appears on legal documentation *
FIRST NAME of Student attending the trip, as appears on legal documentation *
Student Gender *
Benadryl Permission
#1. The school nurse has my permission to administer Benadryl (diphenhydramine) every four to six hours if needed, not to exceed four doses in a 24 hour period. *
#2. Please select in what circumstance the school nurse may administer Benadryl to your child. (Note: you can select one, multiple, or all options).
Zyrtec or Claritin Permission
#1. The school nurse has my permission to administer EITHER Zyrtec (Cetirizine) 10 mg OR Claritin (Lortadine) 10 mg. This will be administered for seasonal allergies and only one dose in a 24 hour period will be given. PLEASE ONLY SELECT ONE OPTION! *
Ibuprofen Permission
#1. The school nurse has my permission to administer Ibuprofen. *
#2. Please select in what circumstance the school nurse may administer Ibuprofen to your child. (Note: you can select one, multiple, or all options).
Clear selection
I understand, with my electronic signature on this form, that my child may be given Ibuprofen every 6 hours not to exceed 6 tablets in 24 hours. If my child presents with other symptoms that day (i.e. sore throat, stomach ache) and above symptoms checked are included, no medication can be given.                                                 I further understand that if my child has a headache due to an injury to his/her head, then Ibuprofen cannot be given.
Tylenol (Acetaminophen) Permission
#1. The school nurse has my permission to administer Tylenol (Acetaminophen). *
#2. Please select in what circumstance the school nurse may administer Tylenol to your child. (Note: you can select one, multiple, or all options).
I understand, with my electronic signature on this form, that my child may be given Acetaminophen (Tylenol) every 4 to 6 hours not to exceed 3 grams per day. If my child presents with other symptoms that day (i.e. sore throat, stomach ache) and above symptoms checked are included, no medication can be given.  I further understand that if my child has a headache due to an injury to his/her head, then Acetaminophen (Tylenol)  cannot be given
TUMS PERMISSION
TUMS The school nurse has permission to administer TUM (Calcium Carbonate 750mg) every 4-6 hours *
Please select in what circumstance the school nurse may administer TUMS to your child. (NOTE: you can select one, multiple, or all options *
Required
This permission is in effect for the Senior Class Walt Disney World Trip March 6th through March 10th, 2023.
School Physician Signature
Acknowledgement of the Physician's Signature *
Name of Parent or Guardian completing this form *
Date Completing This Form *
MM
/
DD
/
YYYY
PARENT ELECTRONIC SIGNATURE, acknowledging the General Over-the-Counter Medication Parental Consent Form is complete to the best of my knowledge. By selecting the "YES" checkbox, you are signing this Agreement Electronically.
PARENT ELECTRONIC SIGNATURE *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms