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9758 E Highland Rd. Howell, MI 48843810-632-2200 phone810-632-2201 faxSchool Year 1032 Karl Greimel Dr. Brighton, MI 48116810-225-9940 phone810-225-9941 faxParent/Guardian Permission for OVER-THE-COUNTER (OTC) MedicationOnly one medication per formName Classroom Age_ Date of Birth Weight (if required for dose) Medication name Exact Dose Condition for use (such as headache) _YES NO Medicine to be taken with food?Other directions YES NO Parent/Guardian to be notified with every use of this medicationFor High School or Middle School students only: (please check option 1 or 2 below) 1. Student can self-administer medication(s) in the presence of an authorized staff memberEXCEPT AT MIDDLE SCHOOL CAMP. 2. Student can keep the medication(s) in his/her possession and self-administer as neededEXCEPT AT MIDDLE SCHOOL CAMP.Other times to call or special instructions-OTC medication without a doctor’s written permission will have limited use at school – SEE PAGE 2 F0R RULESParental PermissionIt is my understanding that the Academy has taken every precaution to safeguard my child. I release and agree to hold the Academy, its Board members, staff working at the Academy, volunteers, and agents harmless from any and all liability foreseeable or unforeseeable for damages or injury resulting directly or indirectly from the administration of the medication/treatment.I also agree to defend, indemnify, and hold harmless the Academy, its Board members, staff working at the Academy, volunteers and agents from and against any such claims, demands, suits, damages, liability, costs, and expenses (including reasonable attorney fees) incurred as a consequence either directly or indirectly of the granting of this authorization to administer the medication/treatment.I have read the guidelines on page three of this form for the administration of over-the-counter medication at school. I give my permission for the above named medication (supplied by me) to be given by school staff as directed on this form.Parent/GuardianSignatureDatePhone Number Alternative number Guidelines for parents and school staff regarding over-the-counter (OTC) medication at school without an order from a physician/licensed prescriber:??All medication must be in the original container and an unopened container is recommended.??Write the exact dose (amount of medication to be given, not a range) on page 1 of this form.??Write your child’s name on the medicine bottle or packaging without covering the label.??Only one medication per form. You will need a separate form for every over-the-counter medication.??Write the exact name of the medication to be given on page 1 of this form.??Write the condition for use (such as, headache or menstrual cramps.)??Aspirin will not be given to students without a doctor’s order on a “Prescription Medication” form due to itsassociation with Rye’s Syndrome.??Stomach pain will not be treated with acetaminophen, ibuprofen or naproxen without a medical order on the“Prescription Medication” form due to lack of indication. Menstrual cramps are not considered stomach pain.??No over-the-counter medication will be given frequently or for a prolonged period of time. If your child is experiencing the need for frequent or regular administration of this medication at school, you will be notified. To continue giving this over-the-counter medication, a physician or licensed prescriber’s order will be required. This is to help insure that a serious condition is not being ignored or a more appropriate treatment is not being overlooked.??If your child is sick it is not appropriate to treat the symptoms at school. Medication may help symptoms briefly or reduce a fever, but he or she is still contagious and should go home.??Cough drops have the potential to be a choking hazard and should only be used for short period of time. If yourchild’s cough persists, a medical professional should be consulted.??Over-the-counter Benadryl or other antihistamines ordered for a potentially life threatening allergy (anaphylaxis)must be ordered as part of the Severe Allergy Medical Action Plan (MAP) and signed by the physician.??Over-the-counter Benadryl or other antihistamines for mild food allergies must be ordered by a licensed prescriber and can be done on the “Prescription Medication” form without completing a Medical Action Plan for severe allergy. Parent/guardians may order over-the-counter antihistamines only for mild allergies that are not caused by food, such as hay fever.??For the purpose of this form, over-the-counter medication includes vitamins and homeopathic remedies.NOTE:??The very first dose of this medication type may not be given at school since it is not known how your child may react to the medicine.??Unused medication may be picked up by a parent/guardian anytime before the end of the school year. Medication remainingafter the last day of school will be properly discarded.Parents/guardians have the right to come to school and give medication to their child without an order form on file. However, all sick children should be home to help protect others.If you have questions regarding the guidelines above, please feel free to contact the school.Parent/Guardian Signature Date ................
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