Saint Agnes School
   Health Office
(781) 641-6047

OVER THE COUNTER MEDICATION 

Student's Name _____________________________________________

Allergies __________________________________________________

Dear Parents/Guardians,

    With your permission, we will dispense any of the medication/s you check off when deemed necessary.  We ask that you sign below if you would like your child to receive this service.  This will not be done without your approval.  Due to changing medical conditions, permission needs to be renewed each school year.
Thank you in advance for your cooperation.

Acetaminophen (Tylenol) ______    Ibuprophen (Advil, Motrin)

Tums ______    Bacitracin ______ Caladryl lotion ______

Cough & Cold medicine _____ Cough drops _____

Please circle dosage strength    Children's    or    Adult

Name of parent or guardian: _______________________ Relationship: ______

I the undersigned parent or guardian, give permission to the school nurse (or school personnel delegated by the school nurse) to administer the above medication to my child.  I authorize the school nurse to share information about the medication administration as the school nurse deems necessary for the health and safely of my child.

signature or parent or guardian ___________________________ date _________

I am aware I will be notified by note from the school nurse if this medication
is distributed during the school day.

Please list any allergies: __________________________________________

_________________________________________
Parent Signature