Village Christian School Health Office Medication Authorization

California State Law requires we have parental approval before we can administer any over the counter medications to students. Please complete this form to pre-approve administration of medications carried by the VCS Health Office. This approval will remain in effect until revoked or changed by parent or guardian.

Today's date: Today's date: / MM / DD YYYY
Student's Name: Student's Name: First Last
Grade Level:
Birthdate: Birthdate: / MM / DD YYYY
Acetaminophen (ie: Tylenol), Dose: 10mg/kg, every 4 hours for fever/pain

Acetaminophen (ie: Tylenol), Dose: 10mg/kg, every 4 hours for fever/pain YES NO
Benadryl, Dose: 1mg/kg, every 6 hours for allergy/itching

Benadryl, Dose: 1mg/kg, every 6 hours for allergy/itching YES NO
Cough drops, Dose: one, every 2 hours for cough/sore throat

Cough drops, Dose: one, every 2 hours for cough/sore throat YES NO
Ibuprofen(ie: Advil), Dose: 10mg/kg, every 4 hours for fever/pain

Ibuprofen(ie: Advil), Dose: 10mg/kg, every 4 hours for fever/pain YES NO
Loratadine(ie: Claritin), Dose: 10mg, every 24 hours for allergies

Loratadine(ie: Claritin), Dose: 10mg, every 24 hours for allergies YES NO
Tums, Dose: one or two, as needed for upset stomach

Tums, Dose: one or two, as needed for upset stomach YES NO
I request that a designated member of the school staff administer these medications to my child as listed in accordance with school policy. I also understand that this approval to dispense the agreed upon medications will remain in effect until revoked. To change or revoke the approval, please contact the Health Office at (818) 767-8382 x 240. The electronic signature below and its related fields are treated by Village Christian School as a physical handwritten signature on a paper form.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Parent/Guardian Name Parent/Guardian Name First Last