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Over the Counter Medication Release : Benadryl, Tylenol, Sunscreen

Full Name of Student

Birthdate

Known Allergies

Weight as of August 2024

I give permission for CBI Forest School to administer the following over the counter medications or lotions

I give permission for CBI Forest School to administer the following over the counter medications or lotions

Parents/caregivers will be notified prior to administration except in the case of emergency.

Date consent form completed:

I, parent/legal guardian, authorize the child day program to administer the medication as specified in the “Licensed Authorized Prescriber Section” to

Child's Name

Date authorized:

Parent/Guardian Signature

Signature

CBI Forest School 434-295-6382

My signature indicates that all information needed to give this medication has been given to the child day program.


Parent's Signature

Signature

Authorized child care provider’s signature: