Over-the-Counter Non-Prescription Medication Permission Form

Parent/Guardian Permission: I give permission for my child (listed above), to self-administer over-the-counter medication[s] such as acetaminophen, ibuprofen, naproxen, tums, etc… at school. The medication must be in the original container and must be used in a manner consistent with labeling instruction and not shared with any other student. No products containing ephedrine or pseudoephedrine are allowed. The privilege to self-administer non-prescription medication will be revoked if the student does not follow the above guidelines.

Students must provide their own medication in the original container. The school does not provide any medication.

This permission is valid for students in grades 6-12 for the current school year only.