Download The following form must be filled out and signed by your child`s

Wappingers Junior High School
4
OVER-THE-COUNTER (OTC) MEDICATION AUTHORIZATION
Student Name: ___________________________________________________
If your child uses an OTC not listed below, have the doctor list the OTC and approve it in the space provided.
Dosage and frequency must be written out. Instructions on a medication’s bottle or box are not acceptable.
Drug Name
Dosage
Requires
Refrigeration
(Yes/No)
Frequency
Possible
Side
Effects
Indications
Health Provider
Order
Tylenol/generic
Pain or fever
Yes
No
Advil/Ibuprofen
Pain or fever
Yes
No
Robitussin/generic
Yes
No
Pepto-Bismol
Cough
Upset stomach,
diarrhea
Yes
No
Mylanta
Upset stomach
Yes
No
NyQuil
Flu symptoms
Yes
No
DayQuil
Flu symptoms
Yes
No
Sudafed
Nasal congestion
Yes
No
Dramamine
Yes
No
Dimetapp
Motion sickness
Nasal congestion,
allergy
Yes
No
Benadryl
Allergic reactions
Yes
No
Hydrocortisone
cream
Allergic reactions
Yes
No
Allergic reactions
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Calamine lotion
Other OTCs
a)
b)
c)
d)
e)
f)
I authorize a designated Wappingers Junior High School staff member during the 7th grade trip to Boston to
oversee the administration of the medication listed above by my self-directed child. I hereby release the
designated school personnel and the Board of Education of any liability relative to the administration and/or
reaction of the medication on the above-named student.
Parent/Guardian signature ____________________________________
I authorize WCSD school personnel to oversee the administration of the medication listed above by my selfdirected patient.
Physician’s signature: _____________________________________ Phone #: ______________________