Forestlake.k12.mn.us

FOREST LAKE AREA SCHOOLS
OVER-THE-COUNTER MEDICATION
AUTHORIZATION FOR ADMINISTRATION OF MEDICATION
2009 – 2010 SCHOOL YEAR

Student _____________________________Date ________________ Date of Birth ________________
Parent/Guardian _______________________________________________________________________
School ________________________________________ Grade _________________________

To Authorized School Personnel:

I hereby request and authorize you to administer to ___________________________________________

Name of Medication ________________________________ (see below or back of form for approved medication)
Dosage (per label directions)_________________________________________ Student’s Weight______
Allergies _____________________________________________________________________________
Time (or Frequency) ____________________________________________________________________
Reason for Use ________________________________________________________________________
The school intends to use the requested information to provide for your child’s health and safety needs
while at school. You may refuse to supply the requested personal information. There will be no
consequence for not providing the information. It may result in an incomplete health and safety plan for
your child. The information you provide will be shared only with staff in the school whose jobs require
access to this information to ensure your child’s safety and school success.
I release school personnel from the liability in the event any reaction results from the administration of this
medication.
__________________________________________ Phone No. ______________________________(H)
Parent/Guardian Signature
Phone No. ______________________________(W) Phone #___________________________(Cell)
Inspire the learner; ignite the potential! Forest Lake Area Schools • Independent School District 831 • Equal Opportunity Employer Over-The-Counter Medications
Allowable per Parent /Guardian request and signature.
Only Middle School & High School Students
 Acetaminophen: common brand name Tylenol
 Diphenhydramine: common name Benadryl
 Chewable Antacids: common names Tums, Maalox
 Cough Drops
 Antibacterial Ointment: common names Neomycin, Bacitracin
Parent/guardians must complete and sign an Authorization of Administration of Medications
form (yearly) before school staff will administer over-the-counter preparations.
Over-the-counter preparations must be provided in the original labeled container. All
medications must be transported to and from school by a parent/guardian.
Over-the-counter preparations will only be administered to a student according to the label
direction’s, unless contrary written directions from a physician are provided.
The health office will not have a supply of allowable medications
The school nurse has the ultimate authority and responsibility to reject a parent’s request and
to decline to administer an over-the-counter medication. If the nurse believes that such
medication is unnecessary, inappropriate, excessive or could lead to patient harm.
Medications will need to be picked up (by a parent or guardian) at the end of the school year.
Remaining medication will be destroyed.
Inspire the learner; ignite the potential! Forest Lake Area Schools • Independent School District 831 • Equal Opportunity Employer

Source: http://www.forestlake.k12.mn.us/_asset/n84bz6/MedicationAdministrationForm0910.pdf