Over the Counter Medication Approval

 MEDWAY PUBLIC SCHOOLS Over­The­Counter (OTC) Medication Approval Form Dear Parent/Guardian: Our medication protocol requires a physician's order and parental signature in order for the school nurse to dispense both prescription and over­the­counter medication. However, this form will allow for certain medications to be administered without an order on a limited basis. With the goal of keeping students in class and ready to learn, and due to the often unpredictable nature of pain, the school nurse at Medway High School is able to administer up to 4 doses of Tylenol or Ibuprofen for pain or fever during the school year without a physician’s order. If you know that your child will experience symptoms requiring these medications on a regular basis please provide the school with a physician's order and a supply of medication. Please return this form to the attention of the school nurse at the beginning of the school year. Thank you for your cooperation Christine Babicz MSN, RN Nurse Leader Medway Public Schools School Nurse Medway High school 88 Summer Street, Medway, MA 02053 508­533­6643 X5108 Fax 508­533­3246 [email protected] ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­ Consent Student’s printed name ______________________________________________________________Grade_____________ I (parent/guardian printed name)_________________________________ grant consent to have the school nurse at Medway High School or personnel designated by the school nurse to administer the following over the counter medications to my child on a limited basis ( a check indicates consent to each med below) __________Acetaminophen (Tylenol) 325­650 mg according to weight, up to 4 doses during school year __________Ibuprofen ( Advil, Motrin) 200­400mg according to weight, up to 4 doses during school year __________Benadryl, according to weight, for allergy symptoms * I understand that if my child needs either analgesic medication more often than stated above, and/or has a history of headaches, migraines, menstrual cramps, or musculoskeletal injuries, I am responsible for obtaining a physician's order and supplying the necessary medication. The new medication form for 2014­2015 school year is available on the website. It can be downloaded, completed, and returned to the school nurse. __________________________________________________________________________________________________ Parent/guardian Signature