Medication Permission & Recording Form



Medication Permission & Recording Form

Please fill out the following information about medications your child will require to have administered.

All medication must be labeled with the child’s name and in original container. Prescribed medications must also be in original container and labeled with child’s name, name of drug, directions for dosage and physician’s name.

Child’s Name:

Last First Age

|Medication |Date Needed |Time (s) |Dosage |When was last dose? |

| | | | | |

| | | | | |

| | | | | |

|Given by |Dose/s |Date/Times |Initials/Comments |

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| | | | |

| | | | |

[pic]

|Medication |Date Needed |Times |Dosage |When was last dose? |

| | | | | |

| | | | | |

| | | | | |

|Given by |Dose/s |Date/Times |Initials/Comments |

| | | | |

| | | | |

| | | | |

[pic]

|Medication |Date Needed |Times |Dosage |When was last dose? |

| | | | | |

| | | | | |

| | | | | |

|Given by |Dose/s |Date/Times |Initials/Comments |

| | | | |

| | | | |

| | | | |

[pic]

|Medication |Date Needed |Times |Dosage |When was last dose? |

| | | | | |

| | | | | |

| | | | | |

|Given by |Dose/s |Date/Times |Initials/Comments |

| | | | |

| | | | |

| | | | |

Parent/Guardian Signature: ________________________________ Date: _____________

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