PDF ADMINISTRATION OF OVER-THE-COUNTER MEDICATION School Year ...
Bishop McNamara High School ADMINISTRATION OF OVER-THE-COUNTER MEDICATION
School Year 2017-2018
Dear Parent or Guardian: To request that Bishop McNamara High School administer any Over-the-Counter medication to your child at school, the following is required:
The physician's signed dated authorization for selected medication at school. Parent signed dated authorization to administer selected medication at school. Parent provided over-the-counter medication is in the original manufacturer's labeled container Parent/Guardian only must bring medications to the school Nurse's office Child's name must be written on the container Physician's directions, if differing from manufacturer's instructions Annual renewal of authorization and immediate notification, in writing, of changes.
Please take this form to your physician for his/her signature and instructions for administration if differing from manufacturer's instructions.
Student's Name: _________________________________________________DOB_______/_______/_______
Over-the-counter medication
Advil / ibuprofen Allegra / fexofenadine Bio freeze/Icy Hot Calamine lotion Children's acetaminophen Children's ibuprofen Claritin / loratadine Cold medicine/cough syrup Cough drops Eye drops Hydrocortisone 1% / anti-itch cream Neosporin antibiotic ointment Tums / calcium carbonate Tylenol / acetaminophen Zyrtec / cetirizine
Who provides
School provides School provides School provides School provides School provides School provides Parent provides Parent provides School provides School provides School provides
School provides School provides School provides Parent provides
Sign if you want this given
Physician's instructions, if differing from product label
I request the above student be given the over-the-counter medications I have signed for above on an as needed basis at school and school activities by qualified staff, according to the manufacturer's instructions or the physician's instructions if they should differ.
I understand the law provides that there shall be no liability for civil damages as a result of the administration of medication where the person administering the medication acts as an ordinarily reasonably prudent person would under the same or similar circumstances. I agree to provide safe delivery of medications to and from school and to pick up remaining medication and equipment.
Parent or Guardian: _________________________________________ Date: ________________________ Physician's Signature: ______________________________________ Date: ________________________ Physician's Printed Name ___________________________________________________________________ Physician's Address _______________________________________________________________________ Physician's Phone_______________________________________Fax________________________________
Bishop McNamara High School 6800 Marlboro Pike Forestville, Maryland 20747 301-735-8401
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