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Authorization for Medication Administration (one per student)

Medication authorization

2023/2024 school year

Please complete the form below. Required fields marked with an asterisk *

Medication authorization

I give permission for the following medicines to be administered*
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Tylenol as directed on label according to age or weight
Ibuprofen as directed on label according to age or weight
Benadryl as directed on label according to age or weight
Cough medicine as directed on label according to age or weight
TUMS or Pepto-Bismol as needed
DayQuil (high school only) as directed on label according to age or weight

Over the counter medication that is sent from home to be taken during school hours, must be brought to the academy office at the beginning of the school day accompanied by instructions as to how much medicine and a time when they are to receive it.  Medications are not be to carried or kept in the child’s backpack, desk, or locker.  This is for the protection of ALL students. 

If your child is under a doctor’s order to take a prescription medication during school hours, we must have a signed Licensed Prescriber Medication Order form signed and on file.  (ask the school office for the form) 

The school office will not have a large supply of cough drops.  Students may bring cough drops with them to school.  A permission note from the parent is required.  Elementary students should give the note to their teacher.  Secondary students should have the note signed by the school office. 

I, hereby give permission to the school nurse or other designated school employee to administer medication to my child.  I understand that the designated school employee shall not be liable to the student, parent, or guardian of the student for civil damages for any personal injuries to the student, which result from acts and omissions in administering any medication.

Signature of Parent or Legal Guardian (I have read the above and certify that this is my digital signature)*
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