Permission to Dispense
Over-the-Counter Medications

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Type of Medication

The student is authorized to be administered this Medication

(to be completed by the student's parent(s)/guardian(s)

Description of symptoms for which Medication should be administered

(to be completed by the student's personal physician)

The student is authorized to be administered this Medication

(to be completed by the student's personal physician)

Acetaminophen

Acetaminophen Approved by Guardian

Headache, mild bruising and/or sprains, cramps

Acetaminophen Approved by Physician

Ibuprofen

Ibuprofen Approved by Guardian

Headache, mild bruising and/or sprains, cramps

Ibuprofen Approved by Physician

Antacid Tabs

Antacid Tabs Approved by Guardian

Peptic gastritis and/or mild abdominal pain

Antacid Tabs Approved by Physician

Cough Drops

Cough Drops Approved by Guardian

Scratchy throat and / or dry cough

Cough Drops Approved by Physician

Sore Throat Lozenges

Lozenges Approved by Guardian

Scratchy throat and / or dry cough

Lozenges Approved by Physician

Topical Antibiotics

Antibiotic Approved by Guardian

Cuts, scrapes and / or abrasions

Antibiotic Approved by Physician

Topical Benadryl gel

/ lotion

Benadryl Approved by Guardian

Insect bites and / or pruritic allergic skin reactions

Benadryl Approved by Physician

Physician's Signature

NOTE: No Over-the-Counter Medication will be given without a physician's signature or office stamp.

I/we do hereby authorize St. Martin's Lutheran School to dispense to the above-named student the Over-theCounter Medication(s) indicated above in instances where St. Martin's Lutheran School and/or its employees/agents in its/their sole discretion deem it appropriate. I/we hereby affirm that I/we am/are aware of the various risks and/or side effects which could be attendant to the Over-the Counter Medication(s) listed above and hereby knowingly, on behalf of myself/ourselves, my/our child, and all of my/our personal representatives agree to indemnify and hold St. Martin's Lutheran School, its agents and its employees harmless from any liability and/or potential claim(s) that may arise in connection with any adverse reactions, side effects and/or other harm that may result from said student/s ingestion/use of those Over-the-Counter Medication(s) indicated above which I/we have authorized St. Martin's Lutheran School to administer to said student.

Physician's Signature

Saint Martin's Lutheran School of Annapolis

Main Office: (410) 269-1955   |   Admissions: (410) 263-8016

1120 Spa Road Annapolis, MD 21403