Over the counter
(Non-Prescription) “As Needed”
AUTHORIZATION TO ASSIST COMPETENT STUDENTS
WITH SELF-ADMINISTRATION OF MEDICATION
Dear Parent(s),
The self administration or assisted administration of non-prescription/over the counter medication may be done at school following these guidelines:
1. Parent or legal guardian must complete this authorization form. All medication (this includes topicals as well
as cough drops, Tylenol, or Motrin) must be brought to the office by the parent.
STUDENTS ARE NOT ALLOWED TO BRING THEIR OWN MEDICATION TO SCHOOL.
2. The medication must be in the manufacturer’s original bottle, sealed, with the student’s name on the
bottle/box. No open containers will be accepted.
3. No medication can be given after the expiration date.
_________________________ _____________ _______ _____________ ___________________
___________________________ __________________ To be
administered at ____________
Name of Medication Dosage and Route
Time
PARENT/GUARDIAN
PERMISSION:
I
acknowledge that the above named student is competent to self administer this
medication with the assistance from the nurse or designated school employee
while in attendance at school. I give
permission for my child to self-administer this medication with the supervision
of a designated school employee. I grant
the school nurse permission as necessary to discuss the prescribed medication
with the below named physician. I agree to hold Williamson County Board of
Education harmless for the administration of such medication. I give
permission for my health care provider and
________________________________ ________________ ___________________
Name of parent/guardian
Home # Work
#
______________________________________ ______________
Signature of parent or
guardian
Date
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Form #5