Trinity School at Meadow View

Trinity School at Meadow View

Medication Authorization for Over the Counter Medication (TMV-HF1)

2015 – 2016

TO BE COMPLETED BY PARENT OR GUARDIAN IN ORDER FOR DESIGNATED TSMV PERSONNEL TO ADMINISTER OCCASIONAL OVER THE COUNTER (OTC) MEDICATION WHEN NECESSARY.

Student Name (Last, First, Middle): ______

Date of Birth ______

Known Drug Allergies: ______

Trinity School keeps a supply of Tylenol, Advil, Aleve (or their equivalents) that can be given by designated school personnel when necessary. If you think your student, at any time during the school year, may have need of these medications, please fill this form out.

Parents or students may bring other over the counter medications to the Front Desk in their original box or container with the student’s name clearly attached. It will be kept in a locked school medication box at the Front Desk. The medication must be accompanied by written Parental Permission.

Please check parent permission for medications to be dispensed as needed at school. We will follow the recommended dosage and frequency as labeled unless specified:

Tylenol (or equivalent) by recommended dosage and frequency

Other dosage and frequency: ______

Advil (or equivalent) by recommended dosage and frequency

Other dosage and frequency: ______

Aleve (or equivalent) by recommended dosage and frequency: ______

Other dosage and frequency: ______

Other OTC medication (original box or container with the student’s name clearly attached)

Name of medication (properly labeled): ______

Dosage and frequency: ______

I hereby request designated school personnel to administer medication as directed by this authorization. I agree to release, indemnify, and hold harmless the designated school personnel, or agents from lawsuits, claim expense, demand or action, etc., against them for helping this student use medication. I understand that the person administering the medication may or may not be trained in the administration of medications. I knowingly consent to these procedures and request that the medication be administered.

______

Parent or Guardian Name (Print or Type) Parent or Guardian (Signature) Date

FOR OFFICE USE ONLY

Received:

Signatures complete: Student Initial (last name):

Employee initials: ______