Medication Info

Notice Regarding Medication Administration Including Tylenol Ibuprofen


A medication form must be completed prior to the administration of any medications.  No medications will be administered without a completed medication form on file with the school nurse.  When completing a medication form, only one medication can be included on each form.  Forms may be obtained from the school office or from the school district web site under the nurse heading.


Medication forms must include the following information:

1.                   Student name, birth date, grade, parent or guardian name, address and phone number.

2.                   Name of medication

3.                   Dosage of medication

4.                   When the medication is to be administered at school

5.                   Prescription medications require written and signed instructions from a physician.  Parent or guardian signature is also required.

6.                   Non prescription medications require the signature of parent or guardian only.  No physician signature required.


*All medications must be in the original labeled container.


*An inhaler is a prescription medication, thus requiring a medication form signed by both physician and parent.  The physician must give permission for the student to carry and self-administer the inhaler.


Ibuprofen and Tylenol

The Middle School and High School has a supply of ibuprofen and acetaminophen that may be administered to any student that has written permission from parent or guardian.  Parent or guardian permission over the phone will not be accepted.


Only the following dosage of acetaminophen and ibuprofen will be administered from the school supply:

                Acetaminophen 325 mg

                                Children under 12: One tablet every four to six hours

                                Children over 12: One to two tablets every four to six hours

                Ibuprofen 200 mg

                                Children over 12 only: One to two tablets every four to six hours


Thanks for your cooperation,

Student Name: _________________________  Birthdate: _________________  Grade: ______________


Parent/Guardian Name: __________________________________________________________________


Address: ___________________________________________________     Phone: __________________





 DAILY Medication:  Diagnosis:  _________________________________________












Side effects to be reported to Physician














PRN Medications:  Administer for the following symptoms:  ____________________________________












Side effects to be reported to Physicians














I agree to retain the power to direct, supervise, decide, inspect, and oversee the administration of the above medication(s).



Student may carry inhaler and self-administer.



_________________________________    _________________________________    ________________

Physician Name (please print)                          Physician Signature                                             Date



______________________________________________________________        ____________________

Address                                                                                                                                                  Telephone #





Dear Parent/Guardian: Please complete and return this to the North Kern Christian School office staff.  This is all that is required for non-prescription medication.  If this is a prescription medication, the Physician’s Orders (above) must be signed by the doctor.




Name of Medication: _______________________________________   Dosage: ____________________

                                (i.e.  Ibuprofen – 200 mg. OR Tylenol – 325 mg. tablets)                       (i.e. 1 or 2 tablets)


When is it to be given at school:  _________________________________________________________

                                                                (i.e. Every 4-6 hours as needed.)


I hereby give my permission to authorize personnel of North Kern Christian School to give medication to my child as described above.  I agree to hold North Kern Christian School, its employees and agents who are acting within the scope of their duties harmless in any and all claims arising from the administration of this medication at school.


I hereby give permission to the school nurse to contact the child’s physician, if needed.  I give consent for this information to be shared with relevant staff.  I agree to contact the school nurse if any changes occur with the above request.


                __________________________________________                              ________________________

                                Parent/Guardian Signature (Required)                                            Date