Acetaminophen/Ibuprofen Permission Form

Medication is administered during the school day to enable all children to remain in school, to maintain or improve health status and to improve the potential for education. The school staff may administer Tylenol (acetaminophen) or ibuprofen once daily so that students experiencing minor pain or discomfort due to a headache, toothache or menstrual cramps are able to remain in school and avoid an unnecessary absence. The school staff, at his/her discretion, may contact you to discuss the frequency of your child receiving acetaminophen or ibuprofen during school hours. He/she may recommend follow-up with your health care provider as needed. However, before administering, all student must have written parental permission on file, to be updated each school year.

STATE LAW REQUIRES WRITTEN PERMISSION FOR ANY STUDENT TO TAKE MEDICATIONS DURING SCHOOL HOURS. THIS INCLUDES ANY OVER THE COUNTER MEDICATIONS.

Student #1 Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Date Of Birth: REQUIRED Please fill out this field. Please enter a date.
Grade: REQUIRED Please fill out this field.
List any allergies: REQUIRED Please fill out this field.
List current medications: REQUIRED Please fill out this field.
List any medical conditions: REQUIRED Please fill out this field.

Permission to Receive Medication

Choose from the following: Acetaminophen (Tylenol) 500 mg (1 tablet) Acetaminophen (Tylenol) 1000 mg (2 tablets) Ibuprofen 200 mg (1 tablet) Ibuprofen 400 mg (2 tablets)
REASON FOR MEDICATION: Aches/pain/cramps Other reason
Beginning: (month/year) REQUIRED Please fill out this field. Please enter valid data.
until the end of the current school year only
or until... Please enter valid data.

I DO NOT consent for any medication to be given to my child Yes

Student #2 Information

First Name Please enter valid data.

Last Name Please enter valid data.
Date Of Birth: Please enter a date.
Grade:
List any allergies:
List current medications:
List any medical conditions:

Permission to Receive Medication

Choose from the following: Acetaminophen (Tylenol) 500 mg (1 tablet) Acetaminophen (Tylenol) 1000 mg (2 tablets) Ibuprofen 200 mg (1 tablet) Ibuprofen 400 mg (2 tablets)
REASON FOR MEDICATION: Aches/pain/cramps Other reason
Beginning: (month/year) Please enter valid data.
until the end of the current school year only
or until... Please enter valid data.

I DO NOT consent for any medication to be given to my child Yes

Student #3 Information

First Name Please enter valid data.

Last Name Please enter valid data.
Date Of Birth: Please enter a date.
Grade:
List any allergies:
List current medications:
List any medical conditions:

Permission to Receive Medication

Choose from the following: Acetaminophen (Tylenol) 500 mg (1 tablet) Acetaminophen (Tylenol) 1000 mg (2 tablets) Ibuprofen 200 mg (1 tablet) Ibuprofen 400 mg (2 tablets)
REASON FOR MEDICATION: Aches/pain/cramps Other reason
Beginning: (month/year) Please enter valid data.
until the end of the current school year only
or until... Please enter valid data.

Student #4 Information

First Name Please enter valid data.

Last Name Please enter valid data.
Date Of Birth: Please enter a date.
Grade:
List any allergies:
List current medications:
List any medical conditions:

Permission to Receive Medication

Choose from the following: Acetaminophen (Tylenol) 500 mg (1 tablet) Acetaminophen (Tylenol) 1000 mg (2 tablets) Ibuprofen 200 mg (1 tablet) Ibuprofen 400 mg (2 tablets)
REASON FOR MEDICATION: Aches/pain/cramps Other reason
Beginning: (month/year) Please enter valid data.
until the end of the current school year only
or until... Please enter valid data.

Signature of Parent/Guardian

I give permission for the school staff to assist the above-named student(s) in taking the above-named medication. With the signing of this permission form, I agree that I will not hold liable the responsible person whose duty it is to assist the student in taking the medication listed above. I also release the responsible person assisting the student from any responsibility for any ADVERSE REACTIONS from the medication.
I AGREE to the above statement Please select this field.
By typing your name in the space below, you are acknowledging that the above information is correct.
Signature of Parent/Guardian/18 year-old student REQUIRED Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.
Email Please enter an email address.

Acetaminophen/Ibuprofen Permission Form

Parent Permission to Receive Acetaminophen (Tylenol) and/or Ibuprofen

2019-2020 Academic School Year

Please fill out one form per family.