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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)
Headache, mild bruising and/or sprains, cramps
Peptic gastritis and/or mild abdominal pain
Scratchy throat and / or dry cough
Sore Throat Lozenges
Cuts, scrapes and / or abrasions
Topical Benadryl gel
Insect bites and / or pruritic allergic skin reactions
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.
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