Permission Form - Tylenol & Ibuprofen

Dear Parent/Legal Guardian,

Health services are provided to all students in the Madison Metropolitan School District by school nurses and nurse's assistants. These services are provided to ensure your child's safety and well being during the school day.

School nurses in all middle and high schools and some elementary schools are able to dispense acetaminophen (Tylenol®) or ibuprofen (Advil® or Motrin IB®) to students with headaches, other discomforts or menstrual cramps.

Your child will only be able to receive these medications with your written permission and subject to the availability of the school nurse. On some days or parts of days, the school nurse may not be in your child's school building so medication cannot be given under these standing orders.

The dosage of the medications is specified in "standing orders" approved by the school district medical consultant, Greg DeMuri, M.D. The dose schedule is below:

1. For HEADACHE or DISCOMFORT, school nurses may give:
   Acetaminophen (Tylenol®) based on weight guideline of approximately 15 mg/kg/dose every 4-6 hours as needed with maximum single dose of 1000 mg.
   OR
   Ibuprofen (Advil® or Motrin IB®) based on weight guideline of 10 mg/kg/dose every 6 hours as needed with maximum single dose of 400 mg.
2. For DYSMENORRHEA school nurses may give:
   Ibuprofen based on weight guideline of 10 mg/kg/dose every 6 hours as needed with maximum single dose of 600 mg.

In general, for students weighing less than 88 pounds, use 400 mg per dose and for those weighing more than 88 pounds, use 600 mg per dose.

If you would like your child to use this service, please complete the bottom of this form and return it to the school nurse at your child's school. A new permission form is required each school year.

Student's Name:______________________  Student Number: _______  Grade: ____

We can only treat your child with your written permission.

We must know if your child has any drug allergies or history of any drug

reactions.  Please list:___________________________________________________

___________________________________________________________________________


__ I give permission for the school nurse to administer acetaminophen
(Tylenol®) or ibuprofen (Advil® or Motrin IB®) to my child for
headache, discomfort or menstrual cramps.

Signature of Parent/Legal Guardian: _______________________________________

Date:______________________
School:________________________________________

Health Information

For more information, contact:
Freddi Adelson, Health Services Coordinator
Madison Metropolitan School District
545 W. Dayton St.
Madison, WI 53703