Laramie Montessori School Medicine Self-Administration Release Form for the 2018-2019 School Year

Laramie Montessori School will now be providing basic medicine that students can self-administer with parental permission. This medicine is for occasional use, not consistent use, so if your student requests medication consistently then we might ask you to provide medication from home for your student. This release is for the over the counter medications listed. If you need your child to take a different over the counter medication or prescription medication you will need to provide it in the original container and fill out the appropriate medicine form provided by the school. Please select the medicines you wish to be available for use by your student. Please also select from the contact options. Understand that all medicine use will be recorded in the student’s medical file which you can request copies of at any time. By signing this form you agree to assume all risks associated with the proper use and self-administration of the selected medicines by the student listed. All staff monitoring the self-administering of medication have had training on proper doses and use of medication. This permission is only good for the school year listed no matter when it is signed.

Ages 5- 9 years: Children’s liquid medicine unless otherwise requested.

Ages 10-13 years: Adult pill medicine unless otherwise requested.

Student Name: ______Age: ______Grade: ______

Medicine Allergies: ______

I DO NOT want my child participating in this option (If you choose this option please skip to signature)

Medicine Choices:

______Ibuprofen (Advil)

______Acetaminophen (Tylenol)

______Antihistamine (Benadryl) – only available for children 6+

Contact choices:

_____I wish to be called every time my child takes a medication

_____I wish to have a paper sent home every time my child has medication

_____I wish to be contacted only if there are side effects or if the medication does not work

Notes/requests: ______

Parent Name:______Parent Signature:______Date: ______Laramie Montessori School Topical Release Form for the 2018-2019 School Year

Laramie Montessori School will be providing some basic topical options that students can use given parental permission. These options are for occasional use, not consistent use, so if your student requests to use one of these options consistently, not including field trips, then we may ask you to provide some for your student at school. This release is for the topical options listed below. If you wish to provide other topical options please make arrangements with the office or your child’s teacher. If you need your child to take a different topical than listed or prescription topical medication you may need to provide it in the original container and fill out the appropriate medicine form provided by the school. Please talk to the office. Please select the medicines you wish to be available for use by your student and sign below. All topical medications will be as hypoallergenic and with as few scents and dyes as possible. If you choose to provide your own topical medications then you are responsible for making sure that your student has them available on field trips or we cannot provide the topical needed. By signing this form you agree to assume all risks associated with the proper use and self-administration of the selected topicals by the student listed. All staff monitoring the self-administering of medication and topicals have had training on proper doses and use of medication. This permission is only good for the school year listed no matter when it is signed.

Student Name: ______Age: ______Grade: ______

Topical Allergies: ______

Topical Medicine Options:

_____sunscreen (available for field trips) _____ I wish to provide my own sunscreen (must be kept in the classroom or office)

_____insect repellent (available for field trips) _____ I wish to provide my own Insect repellent (must be kept in the classroom or office)

_____lip balm (available in office) _____ I wish to provide my own lip balm (does not have to be kept with a teacher or office unless it becomes a distraction)

_____petroleum jelly (available in classroom or office) _____ I wish to provide my own petroleum jelly (must be kept in the classroom or office)

_____skin lotion (available in classroom or office) _____ I wish to provide my own skin lotion (must be kept in the classroom or office)

_____triple antibiotic ointment (available in office) _____ I wish to provide my own antibiotic ointment (must be kept in the office)

Notes/Requests: ______

______

Parent Name: ______Parent Signature:______Date: ______