River Grove: A Marine Area Community School PO Box 178, 14189 Ostlund Trail N, Marine on St Croix, MN 55047 [email protected] • www.marineareaschool.org

Permission to Administer Sunscreen/Insect repellent/Lip balm and OTC Medication Permission Form 2019-20

PART 1) This waiver gives River Grove permission to apply sun screen (SPF 15 or higher), lip balm, and/or insect repellent that is supplied from home. In addition, it gives River Grove permission to give over-the-counter (OTC) medications to your child (not including non-prescription pain relievers). This form is in lieu of a telephone call each time your child requires medication. Parents will be notified if the requests for such medication are excessive. Dosing and formulation of medication will be determined by the school nurse and will be age and weight appropriate.

Child’s Name: ______Grade/Teacher ______

 YES, I hereby acknowledge and request that River Grove staff, its employees and/or duly authorized agents administer or assist in administering sunscreen, lip balm and/or insect repellent to above named child while child is under the supervision of River Grove. In consideration of the administering or assistance in administering sunscreen, lip balm and/or insect repellent, I hereby forever release, discharge, hold harmless and agree to indemnify River Grove, its employees and duly authorized agents of and from any and all claims, demands, suits, actions, and liabilities or responsibilities of whatsoever kind or nature, arising out of connection with the administering or assistance in administering of said sunscreen, lip balm, and/or insect repellent. I understand that these will be applied only right before and as needed during outdoor play.  Sunscreen Brand: ______ Insect Repellent Brand: ______ Lip Balm: Brand: ______The above must be supplied by parent and labeled with the student’s name and grade.

 NO, I do not wish to allow River Grove staff, its employees and/or duly authorized agents to administer or assist in administering sunscreen, lip balm and/or insect repellent to above named child.

PART 2) OTC MEDICATION: In order for over-the-counter (OTC) medications to be given to your child we must have your written permission. This form is in lieu of a telephone call each time your child requires medication. Parents will be notified if the requests for such medication are excessive. Dosing and formulation of medication will be determined by the school nurse and will be age and weight appropriate.

PLEASE INITIAL EACH TOPICAL MEDICATION FOR WHICH YOU ARE GIVING PERMISSION: ______Antibiotic cream (Bacitracin/Neosporin Triple Antibiotic ointment) ______Hydrocortisone cream ______Anti-itch cream (Benadryl cream, Caladryl lotion) ______Aquaphor/Vaseline/Lotion ______Cough drop/throat lozenge

Please note: This form does not give us permission to administer non-prescription pain relievers such as acetaminophen (Tylenol) or ibuprofen (Advil)

 Describe any allergies or additional notes: ______

 NO, I DO NOT WANT ANY OTC MEDICATIONS GIVEN TO MY CHILD

Guardian/Parent Name (print): ______

Signature (Guardian/Parent): ______Date: ______