Holycross-batavia.org

Holy Cross Catholic School
2300 Main Street
Batavia, Illinois 60510-7625
Msgr. Daniel J. Deutsch Tricia Weis
Pastor Principal
630-593-5290
“Jesus said to His disciples, ‘Whoever wishes to come after Me must deny himself, take up his
cross, and follow Me.’” (Matthew 16:24)

Administering Medicines to Students

Dear Parent /Guardian,
The purpose of administering medication in school is to help each child maintain an optimal state of health that
may enhance their educational plan. The law which regulates the administration of medication in the school is
the same as that applied to hospitals and other institutions: Medication of any type will be administered only
with the written order of the child’s physician and parents.

Prescription Medicine and Over-the Counter Medicine (other than Ibuprofen or Tylenol)
If at any time your child will be receiving prescription medication during the school day, the
“Order for Administration of Prescription and Over-the-Counter Medication” (see
attached) must be completed in its entirety and on file in the school office. The form must be
signed by the child’s physician and parent on an annual basis or as needed.
Parents wishing to give the school permission to administer other over-the-counter medication
to their students (with the exception of Ibuprofen or Tylenol as noted below) must also complete
the “Order for Administration of Prescription and Over-the-Counter Medication.” This
document will indicate the medication, dosage, and duration of administration. This form for
other over-the-counter medication also requires the doctor’s and parent’s signature.
ALL medicines that are regularly administered at school, whether prescription or over-the-
counter, must be brought to the school by an adult in the original container. The labeled
container must show the names of the child, dosage, doctor and pharmacy.

Ibuprofen or Tylenol Pain Medications
Sometimes, a child will come to the school office complaining of pain such as tooth ache, ear ache, etc. The only other over-the counter pain medications to be administered by the school
office staff are Ibuprofen or Tylenol. This is only available for students in third grade or above.
In these circumstances, the attached “Order for Administration of Ibuprofen or Tylenol
Medication” (also attached) must be completed, signed by the parent and on file in the school
office. Please be clear about the dosage of pain aid you wish your child to receive.
If the school office determines that fever may be present, you will be requested to come and get Homeopathic/herbal and cold remedies will not be administered by school personnel. If a student needs cough drops, they should be brought from home with a parents’ note. ORDER FOR ADMINISTRATION OF Prescription and Over-the Counter MEDICATION
Please complete in detail for each child requiring medication. Physician and parent must sign this order.

Note: Parent should complete/sign other side for Order of Administration of Ibuprofen or Tylenol Medication

Student Name: ___________________________________________Birthdate:_______________ Grade Level:____________________________________________________________________ Any known allergy(ies): ___________________________________________________________ Parent(s) Name: _________________________________________________________________ Phone Numbers: Home________________ Work: ________________Cell__________________ Licensed prescriber’s name: _______________________________________________________ Address: __________________________________Phone Number: _______________________ Name of Medication and dosage:____________________________________________________ Method and time of administration:__________________________________________________ Date and duration of medication:____________________________________________________ Side effects for which child must be observed:_________________________________________ ______________________________________________________________________________
LICENSED PRESCRIBER:
__________________________________________ __________________________________
PARENT or GUARDIAN:
__________________________________________ _________________________________ ORDER FOR ADMINISTRATION OF Ibuprofen or Tylenol MEDICATION

Holy Cross Catholic School is hereby authorized to administer Ibuprofen or Tylenol (please specify)
when warranted to the following children (please list by name – only applies to 3rd grader and older) in the
dosage indicated here:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
PARENT or GUARDIAN:
_____________________________________________ __________________________________
Signature Date of Signature

Note: Parents must complete/sign other side for Order for Administration of Prescription and Over-the-Counter Medication other than Ibuprofen or Tylenol.

Source: http://www.holycross-batavia.org/hccs/images/school_info/enrollment/2013_2014/2013-2014_Medication_Administration_letter.pdf