Please check the medication you would like your child to receive in school
_____Acetaminophen (Tylenol)
_____Ibuprofen (Advil, Motrin)
_____Benadryl
_____Tums
_____Cepacol cough drops
All dosing will be in accordance with package instructions.
___________________________________ ________________
Student's Name Grade
____________________________________ ________________
Parent/Guardian Signature Date
All other over-the-counter and prescription medications require a physician's
written order AND written consent from a Parent/Guardian. All medication must be in its original container and delivered to the school nurse by a parent or guardian.