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JCS Academy of Art and Science

Acetaminophen/Ibuprofen Permission Slip

Student Name: _______________________________________

My child has medication that may need to be administered during school AND Ihaveattacheda
Physician/MedicationAuthorizationForm (Form is available from Academy Office).
(All prescriptions, except those which must be kept on the students person for emergency use, must be kept and
distributed by the staff. Bring the medication to the front office with a physicians written instructions for dispensing at
first class meeting.)

Check here ifyour son or daughter has permission to receive (circleoneorboth) ACETAMINOPHEN or
IBUPROFEN (1or2tablets) for discomfort. (Medication is supplied by parents and brought to the office for
dispensing as needed)

School administration is intended foroccasionaluseonly.If your child requires any non prescription medication on
a regular basis, you must complete a physician authorization form.

Acetaminophen 325mg (Tylenol) Ibuprofen 200mg (Motrin)


(Circle one or two) Dosage: One or Two Tablets Dosage: One or Two Tablets

Parent/Guardian Signature __________________________________________Date ______________

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