By signing this consent, I, as the parent or legal guardian of the listed student, allow the office staff members to administer all over the counter (OTC) listed below, as requested by the student. The recommended dose per medication packaging will be administered. This consent is valid for the 2024-2025 school year.
Please check all medications that the student may have upon request:
Tylenol (acetaminophen)
Advil, Motrin (ibuprofen)
Cough Drops
Normal Saline eye drops
Tums chewable tabs
Triple Antibiotic Ointment
Student Name
*
First Name
Last Name
Grade
*
(PreK, K, 1, 2, Etc)
Student DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Signature
*
Parent/Guardian Printed Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please contact the School Nurse with any Questions
Kyle Jans, RN BSN, WWG School District Nurse, jansfac@wwgschools.org
Submit
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