We can dispense ibuprofen/acetaminophen to a student on an as-needed basis

PHONE NUMBER FOR EMERGENCY PHONE TREE

(for school wide emergency only) Phone #: _____________________________________
DISPENSING IBUPROFEN/ACETAMINOPEN PERMISSION FORM (This section is NOT OPTIONAL)

Please check one of the choices, sign and date

We can dispense ibuprofen/acetaminophen to a student on an as-needed basis. Please check the following
instructions according to your wishes.

__________ Do dispense ibuprofen/acetaminophen to my student if needed. __________ Do not dispense ibuprofen/acetaminophen to my student.
Student Name________________________________________________________
Parent Signature_________________________________ Date________________

PROCEDURE FOR STUDENT MEDICATIONS

We ask that our parents bring all student medications to the appropriate division office. All medications must be labeled
with the name of the student, the name of the medication, and all necessary instructions. All medications must be
taken by the student in the office under the supervision of an Oak Hall staff member. It is the responsibility of the
student to remember his/her medication.
The following form provides your authorization to a staff member of Oak Hall School to dispense any required
medications to your student. Please complete the form and return to the school before the first day of classes. We
cannot dispense medications until the form is on file in our office.
Student Name ___________________________________________________________
Name of Medication(s)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

Dosage and times
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Special Instructions
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Name of Attending Physician ______________________________________________

Telephone Number___________________________________________

Parent Signature _________________________________ Date __________________

Source: http://www.oakhall.org/Customized/uploads/Parents/2011-2012%20Back%20side%20of%20Emergency%20Form.pdf