St. Thomas Aquinas Academy

Parent/Guardian Consent for Student Medication – Non-Prescription

2016-2017

Please note: This form is intended only for acetaminophen (Tylenol or a generic equivalent) or, if supplied from home, other non-prescription pain relievers such as Advil, etc., or occasional use to relieve temporary conditions such as headache, toothache, etc.  If medications are to be taken regularly for any extended period of time, the office must be notified and separate forms completed.

Students to receive school-supplied acetaminophen or non-prescription medication supplied from home:
Medication listed above will be given to the student by the Principal or Office Manager as needed. Please check your preference: *
I hereby give permission to the authorized school personnel to give acetaminophen or other non-prescription medication to my child according to the directions stated above. I agree to hold the school, its employees and agents who are acting within the scope of their duties harmless in any and all claims arising from the administration of this medication at school. I agree to notify the school in writing at the termination of this request or when any change in the aboe order is necessary. *
I hereby give permission to the authorized school personnel to give acetaminophen or other non-prescription medication to my child according to the directions stated above. I agree to hold the school, its employees and agents who are acting within the scope of their duties harmless in any and all claims arising from the administration of this medication at school. I agree to notify the school in writing at the termination of this request or when any change in the aboe order is necessary.
Date Signed
Date Signed
Mother's Daytime Phone Number *
Mother's Daytime Phone Number
Father's Daytime Phone Number
Father's Daytime Phone Number