St. Thomas More St. Thomas More Catholic Catholic Catholic School

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St. Thomas More Catholic. Catholic. Catholic School. Chapel Hill, NC. Over-the-Counter Medication Permission Form. **To be completed by a Parent**.

St. Thomas More Catholic School Chapel Hill, NC Over-the-Counter Medication Permission Form **To be completed by a Parent** Student’s Name_________________________________________________ Class_________________ Medication: Please check each box for the medication you give permission to. Please circle the appropriate dosage as well (how many tabs or teaspoons).

__Tylenol (Acetaminophen)

160 mg/tab (one) (two) tabs 325 mg/tab (one) (two) tabs

__Motrin (Ibuprofen)

100 mg/tab (one) (two) tabs 200 mg/tab (one) (two) tabs

__Benadryl (Diphenhydramine)

12.5 mg/tsp (one) (two) tsp

__TUMS (Calcium Carbonate)


(one) (two) tabs

Other: _______________________ Dosage _________________ Dates to be given: From______________________ to ________________________ Times to be given:


________PM ______ As Needed

This form will allow the nurse to provide “over the counter” (OTC) medications listed above on an occasional basis to your child. If the named medications are needed on a regular basis, please provide that “over the counter” medication in the original container with the student’s full name written on it. I hereby give permission for my child (named above) to receive the above-mentioned medication during school hours. I understand that the school undertakes no responsibility for the effects of this mediation when it has been properly administered. I hereby release St. Thomas More School and their employees and agents from any and all liability that may result from my child taking the above named medication(s), according to the written instructions I have given. Parent/Guardian Signature __________________________________________________ Date_____________

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