Medication Authorization And Administration Form printable pdf download

Medication Authorization And Administration Form

Medication Authorization and

Administration Form

Section A: To be completed by parent/guardian

Medication authorization for: _____________________________________________ (Child’s name)

All About Kids Sports Center has my permission to administer the following medication:

Instructions for giving my child this medication:

1. Name of medication: _______________________________________________________________

2. Dosage to be given: ________________________________________________________________

3. Time of day for dosage: _____________________________________________________________

4. Route of administration (e.g., mouth, nose, eyes, ears):____________________________________

5. Special instructions (e.g., take on empty stomach): _______________________________________

6. Date to start medication: _____________________________________________________________

7. Date to stop medication: _____________________________________________________________

8. Reason medication is needed: _________________________________________________________

9. Reactions/side effects: _______________________________________________________________

Parent’s or Guardian’s Signature: ______________________________________ Date: _____________

Section B: To be completed with each administration by All About Kids Staff Member

Date

Time

Name of medication

Quantity

Staff signature

Observations

Medication Authorization And Administration Form