Worthington Christian Schools

WORTHINGTON CHRISTIAN SCHOOLS Non-Prescription Medication

Parent’s Request for Assistance in the Dispensing of Student Medication by School Personnel

School policy states that no students may carry or dispense non-prescription medications while at school. I hereby request and give my permission to school personnel to assist in administering medication to my child.

Name of student ______Grade ______Phone ______

Worthington Christian High School will make the following over-the-counter non-prescription medications available in the health office and on certain travel trips and retreats. If you would like your student to be able to take any of the following medications, if needed, please indicate on the line. The following medications will only be administered as needed and according to package instructions. Please note any special instructions beside the medications you select. If you prefer to provide your own supply of over-the-counter medications for your child, please send the medication to the health office in its original container and indicate any instructions.

____Tylenol (acetaminophen) 350 mg tabs ______

____Advil (ibuprofen) 200 mg tabs ______

____Phenylephrine Tabs (decongestant) ______

____Benadryl (diphenhydramine) 25 mg tabs ______

____Benadryl topical cream ______

____Tums ______

____Cough Drops ______

____Antibiotic ointment ______

____I will supply the following medications for my child and indicate the following instructions

1.______

2.______

3.______

I/We understand and acknowledge that school personnel are under no obligation to render the assistance requested and that such assistance may, in the absence of the school nurse, be rendered by an employee of the school who is not medically trained. I/We hereby release Worthington Christian Schools, the School Commission, its officials and employees, including the school nurse and the principal’s designee, from any and all liability for damages or injury directly or indirectly resulting from the performance or failure of performance of the assistance requested.

______Date Parent Signature

Revised 6/10