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OSCA Medicine Admistration Form
2020-21
Student Name
*
By submitting this form I acknowledge that the OSCA staff has permission to administer the following medication(s) during the current school year. Medication(s) not listed on this form will not be administered without parental consent.
Basic first aid is provided as per needed. This could include bandages, antibiotic cream, eye wash, and ice packs.
Parent/Guardian Name
*
Tylenol or Acetaminophen
Yes
No
Advil or Ibuprofen
Yes
No
Tums
Yes
No
Cough Drop
Yes
No
Pepto-Bismol
Yes
No
Cortizone Cream
Yes
No
doTerra Essential Oils
Yes
No
Other Over the Counter Medication Dosage & Dates
Prescription Medication Dosage & Dates
Allergies
Other Instructions
Do not enter anything in this field:
*
indicates a required field
Please fill this field.
