Authorization For The Administration of Aspirin Like Substitute

To be used only for Parental/Guardian Requests for aspirin like substitute (Acetaminophen) without, a physician/dentist order. The state law and regulations permit boards of education and schools to accept requests from parents/guardians to give an aspirin like substitute (acetaminophen) to a student. In such cases the order of a licensed physician or dentist is not required.

Information provided by parent/guardian:

Name of Student:___________________________Date of Request:____________

Address:_________________________________ Date of Birth:______________

Town:_____________________________________________________________

Reason medication is to be given:_______________________________________

__________________________________________________________________

Name of Medication:_________________________________________________

Amount and Frequency:_______________________________________________

Time of Administration:_______________________________________________

Medication to be administrated from:________________ to __________________                                                                 (date)                              (date)

I hereby request that the medication listed above be administered to my child by the appropriate school personnel and in accordance with state regulations. Name of

Child:______________________________________________________

Relationship to Child:_________________________________________________

Signature:______________________________________ Date:_______________

Address:_________________________________ Phone:_______________

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Updated March 19, 2007