PRINCE GEORGE COUNTY PUBLIC SCHOOLS Parent Authorization

HSM 0008-0809. PRINCE GEORGE COUNTY PUBLIC SCHOOLS. Parent Authorization for Administration of. Acetaminophen, Ibuprofen or Naproxen at School...

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PRINCE GEORGE COUNTY PUBLIC SCHOOLS P ar e nt Aut hor i zat i on f or Admi ni s t r at i on of Ac e t am i nophe n, I bupr of e n or Napr oxe n at Sc hool (A s e par at e f or m mus t be c ompl e t e d f or e ach me di c at i on.)

P ARENT/ GU AR DI A N SEC TI O N

Student _______________________________________________________ DOB______________________________ Medication Allergies _______________________________________________________________________________ List of Child’s Medical Conditions ____________________________________________________________________

I, ____________________________________________, parent or legal guardian of above student, request that the principal’s designee at _________________________________ School administer the below medication to my child. In signing this form, I am agreeing to hold the school and its personnel free from any legal action that might arise from this arrangement. I also understand that I am to abide by the school division regulations as stated below: • It is my child’s responsibility to come to the clinic to take his/her medication. • Parent or guardian must bring medication into school office or clinic. Medication cannot be transported on buses or by students. • Medication must be in the original, unopened container, labeled with student’s name. • The first dose of a new medication should be given at home. • Any changes in medication require a new written authorization. • If a child requires medication for 3 or more consecutive school days, parent or guardian will be required to provide written authorization from a licensed prescriber. • Parent or guardian must provide medications/equipment required to administer medications or provide special medical care. • Left over medication must be picked up at the end of the school year or it will be discarded.

Medication (as it appears on bottle): ___________________________________________________________________ Amount or Dosage to be Administered: ________________________________________________________________ Time or Frequency to be Administered: ________________________________________________________________ Reason for Medication: _____________________________________________________________________________ Duration or Length of Time to be Administered: _________________________________________________________

Parent/Guardian Signature ______________________________________________ Date _______________________ Parent/Guardian PRINTED Name _____________________________________________________________________ Home Phone ______________________ Work Phone _____________________ Cell Phone _____________________ HSM 0008-0809

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