Medication Administration Packet
Authorization to Give Medicine
Page 1—To Be Completed by Parent/Guardian
NAME OF FACILITY/SCHOOL TODAY’S DATE
NAME OF CHILD (FIRST AND LAST) DATE OF BIRTH
NAME OF MEDICINE
REASON MEDICINE IS NEEDED DURING SCHOOL HOURS
TIME TO GIVE MEDICINE
DATE TO START MEDICINE STOP DATE
KNOWN SIDE EFFECTS OF MEDICINE
PLAN OF MANAGEMENT OF SIDE EFFECTS
PRESCRIBING HEALTH PROFESSIONAL’S NAME PHONE NUMBER
PERMISSION TOGIVE MEDICINE
I hereby give permission for the facility/school to administer medicine as prescribed above.
I also give permission for the teacher/caregiver to contact the prescribing healthprofessional aboutthe administration of this medicine.
I have administered at least one dose of medicine to my child without adverse eﬀects.
PARENT OR GUARDIAN NAME (PRINT)
PARENT OR GUARDIAN SIGNATURE
HOME PHONE NUMBER WORK PHONE NUMBER CELL PHONE NUMBER