Health-medication form

Listed below are nonprescription medications that the nurses can give to students only with parent permission. We hope that using these medications, as needed, will reduce both absenteeism and student discomfort while in school. If a student needs routine medications, other arrangements should be made. Medications will be given in age/weight appropriate doses. Please fill out this form, giving your permission for your child to get these medications if needed. It will become a part of his or her health file. Check the appropriate boxes and sign the bottom of this form, if you agree
that your child may receive the following medications. Also, please note any medication allergies that your child
may have. No nonprescription medications will be given to students whose parents do not complete and
return this form.

My child may receive the following over-the-counter medications at school:
 Acetaminophen (Tylenol) for headache and fever
 Ibuprofen (Advil, Motrin) for muscle aches and pains, cramps, sinus pain
 Maalox (or comprarable nonprescription antacid) in liquid or tablet form for upset stomach
 Loratadine (Claritin) for allergies and sinus
 Clotrimazole as an antifungal for skin itch and rash
 Ocean Nose Spray (or generic saline nasal spray) for stuffy nose or nasal dryness
 Natural tears (or any saline eye drops) for eye dryness and/or itching
 Visine Allergy Eye Drops for itching eyes
 Cough Syrup (non-alcohol based, such as Robitussin) for dry coughs
 Calamine or Caladryl Lotion (or generic) for itchy rash (not to be applied around the eyes)
 Benadryl (Diphenhydramine HCL) for allergy symptoms
 Topical antibiotic ointment for minor cuts and scrapes
 Topical Hydrocortisone Cream for minor skin irritation and rashes (not to be used on the face)
 Benzocaine Sting Wipes for insect bites and stings
 Oragel (or generic equivalent) for temporary relief of mild toothache
PLEASE PRINT:
Student’s Name_____________________________________________ DOB:_____________________________
Allergies_____________________________________________________________________________________
Age___________
School_____________________________________
Printed name of parent or guardian signing this form:_______________________________________________
As the parent or legal guardian of the above named child, I give permission for the school nurse associated with the
MRH School District to give the above named non prescription medications to my child for the conditions indicated.
Parent Signature_______________________________________________________________________________
PLEASE FILL OUT FORM ON REVERSE
Parent(s)/Guardian(s) Contact
Parent/Guardian Name—(last, first)
Parent/Guardian Relationship to Student: Parent/Guardian Current Address—City, State ZIP Home Phone Emergency Contact—In the event that either parent(s) or guardian(s) cannot be
reached, the person listed below will care for your son/daughter and have permission to
pick up the named student or be contacted in case of emergency.
Emergency Contact’s Name—(last, first)
Emergency Contact’s Relationship to student Emergency Contact’s Current Address—City, State ZIP Home Phone Health History—Check if any of the following applies to your child.
 Asthma
 If your child has other medical conditions/allergies please list them along with any medications your child is currently taking and the condition for which it is prescribed.
Permission for Emergency Medical Care
I herby give my permission to _____________________________(hospital of choice) to carry
out those procedures, which their professional judgment deems necessary in the event that my
child becomes involved in an accident or suffers from any physical condition that threatens life
or physical ability during attendance in the MRH School District. I further give permission to
the school personnel to help secure this care in the event I cannot be notified. I understand that
expenses for ambulance or hospital are not the responsibility of the school.
Parent/Guardian Signature__________________________________________Date__________
PLEASE FILL OUT FORM ON REVERSE

Source: http://www.mrhsd.org/userfiles/files/Expedition%20Health-Medication%20Form.pdf