It appears that the naacp has come in here and created a problem where there is none

SCHOOL MEDICATION PERMIT
For Lakota East Bands Only

(In accordance with Ohio Revised Code 3313.713) The use of medication during school hours is
discouraged. Use this form if it is essential a student receive medication during the school day.

This section to be completed by the Parent or Guardian
Name of Student: ___________________________________________Birthdate: _______________
Student’s Address: _________________________________________________________________
School: ___________________________________ Grade: _________ Homeroom: _____________
I request the school personnel administer the medication as instructed and I agree to 1) Deliver the
medication in the original container and 2) Notify the school if I change physician’s or medication is
changed/eliminated.
I understand it is the student’s responsibility to report on time for this medication. I agree to hold school employees/volunteers and the Board of Education free of responsibility to results of this medication. If physician orders that the student carry an asthma inhaler for self-administration:
1) Provide a second inhaler to be stored in the clinic in the event the student doesn’t have his/hers 2) Student should be responsible to report use of inhaler to nurse for assessment of effectiveness
Parent/Guardian Signature: ___________________________________________Date: __________
Phone # During School/Daytime Hours: ___________________ Other Phone: ________________

This section to be completed by the Physician
Medication: Ibuprofen 200mg tablets, Extra Strength Tylenol, Benadryl 25mg, Sudafed Sinus,
Ioperamide (Imodium AD), Tums EX, and/or Triple Antibiotic Cream.
Dosage to be given: As Directed on package
Time(s) to be given: As Directed on package
Date of Authorization: ___________ Date to Begin: August 1, 2009 Date to End: June 6, 2010
Adverse Reactions to be reported: ______________________________________________________ Special Instructions: _________________________________________________________________ Administration: ______________________ Storage: __________________ Other: _______________ If physician orders student carry an asthma inhaler for self-administration, complete this section:
Procedure to follow if asthma symptoms are not relieved: ____________________________________ Adverse reaction if used by unauthorized person: __________________________________________ This patient has been instructed the proper use of this medication, the expected results and the
possible side effects, and is capable of carrying and self administering this medication.
Physician Name (print please): ________________________________________________________________
Physician Address: _________________________________________________________________________
Physician Signature: ________________________________________________________________________
Physician Emergency Phone #: __________________________ Alternate Phone: ______________________
This section for School Use Only
The following personnel/volunteers have read this form and are authorized to administer
medication as outlined above:
Signature: ________________________________________________________Date: ____________
Signature: ________________________________________________________Date: ____________
Signature: ________________________________________________________Date: ____________

Source: http://lakotaeastbands.org/Band%20Official%20Forms%20&%20Information/2009%20Marching%20Band%20Medication%20Permit%20%20-%20East%20Bands%20Only.pdf