OTC or Non-Prescribed Medication or Treatment Request

The Lewisville School District will assist parents by administering approved non-prescribed medications or treatments for a limited period of time not to exceed five days. The nonprescription medication must be delivered to the school in the original container with a manufacturer’s label identifying the medication, dosage schedule and student’s name. A prescription is required after 5 days.

Name of Student _____________________________ Age _______ Grade __________

Medication _________________________ to take for __________________________

Start date at school ___________ End date at school ___________ (no more than 5 days)

Amount to give __________________ every _________ hours ___________________

Or, administer the medications when these signs and symptoms occur: _____________

____________________________________________ every _____________ hours.

Are you giving this medication at home: Yes _____ No _____

Very Important

Send a note with your student to notify the school of the time of the last dose

at home on the days that we have this medicine at school. If none, state, ‘None.”

Medication requests must be deemed necessary to maintain or improve health and participation in the school program. Each request will be assessed for appropriateness. Indications and directions for nonprescription drugs must be consistent with guidelines found in the Physicians’ Desk Reference for Nonprescription Drugs and must be age appropriate.

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PARENT STATEMENT:

As parent/guardian of the above named student, I request the School District to give medicine named above on this form.

While this request is in effect I will notify the nurse if I give this or other medications to my child before arrival at school to prevent possible reactions or an overdose.

Signature of Parent/Guardian ____________________________________________ Date __________

Home Phone ________________________ Work/Emergency Phone ___________________________

School Nurse Signature _________________ Date __________ School _________________________

Approved ________ Denied __________ (state reason if denied) ______________________________

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