Village Christian School Health Office Medication Authorization

Parent/Guardian approval is required to administer medication to students during school hours. Please complete this form, so that in the case your student needs any of the medications listed below, we may administer them in a timely manner.

Today's date: Today's date: * / MM / DD YYYY
Student's Name: Student's Name: * First Last
Grade: *
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