Medication Dispensing Consent Form - Hoffman Estates Park District printable pdf download

Medication Dispensing Consent Form

This form must be completed for each program session or when medication changes.

Child’s Name: _______________________________________________

Age: __________

Parent Name: _____________________________

Parent Phone Number: ______________

Program / Teacher: ______________________________________________________________

Prescribing Doctor’s Name: ________________________ Phone Number: _________________

Medication Information (completed by the doctor):

Medication: ____________________________

Expiration Date: _________Dosage: _________

Time to be given: ____________ Day:________

Possible side effects: _____________________

Storage Instructions:______________________

Doctor Signature: ______________________________Date: _____________________

I understand that it is my responsibility to give the medication directly to program staff with full

instructions in original prescription bottles or over-the-counter original packaging.

In all cases, medication dispensing can only be changed or modified by completing another

Permission and Waiver to Dispense Medication Form and Medication Information Form.

I hereby acknowledge that the above information provided for the dispensing of medication for my

minor child, guardian, ward, or other family member is accurate. I also understand that it is my

responsibility to inform the agency if any changes in the dispensing of medication change.

___________________________________________

____________________

Parent/Guardian Signature

Date

Completed by program staff:

All prescription medications must be in the original pharmacy labeled bottle and can only be

administered if the answers to all the questions below are “yes”.

1. Is the consent form above completed?

YES / NO

2. Is the medication in a safety cap container?

YES / NO

3. Is the original label on the medication container?

YES / NO

4. Is the child’s name on the medication container?

YES / NO

5. Is the date on the prescription current?

YES / NO

6. Is the medication’s name, dose, and frequency of administration

on the label consistent with instructions given above?

YES / NO

** Only staff trained on administering the prescription may give the prescription to the child.

Staff trained on the prescription are:

________________________________________

Medication Dispensing Consent Form - Hoffman Estates Park District

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