Medication Authorization And Log
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Medication Authorization and Log
Name of Parent/Guardian: _________________________________________________
(Please Print)
I, the undersigned parent or guardian, give permission for employees of United Cerebral Palsy of Greater
Dane County to administer the below medication to __________________________________________________
according to the stated directions below and on the bottle. I have read UCP’s policy for Medication
Administration Policy and understand and agree that United Cerebral Palsy and its employees will not be
held responsible for any ill effects which might occur in connection with the administration of the
medication as defined below.
Signature of Parent/Guardian _____________________________________
Date: __________________________
To Be Completed By Parent/Guardian:
1. Medication and Dosage: _________________________________________________________________________
Frequency and Times: ____________________________________________________________________________
Reason for Medication: ___________________________________________________________________________
Special Instructions:________________________________________________________________________________
___________________________________________________________________________________________________
Side effects that might occur: ______________________________________________________________________
___________________________________________________________________________________________________
2. Medication and Dosage: _________________________________________________________________________
Frequency and Times: ____________________________________________________________________________
Reason for Medication: ___________________________________________________________________________
Special Instructions:________________________________________________________________________________
___________________________________________________________________________________________________
Side effects that might occur: ______________________________________________________________________
___________________________________________________________________________________________________
3. Medication and Dosage: _________________________________________________________________________
Frequency and Times: ____________________________________________________________________________
Reason for Medication: ___________________________________________________________________________
Special Instructions:________________________________________________________________________________
___________________________________________________________________________________________________
Side effects that might occur: ______________________________________________________________________
___________________________________________________________________________________________________
4. Medication and Dosage: _________________________________________________________________________
Frequency and Times: ____________________________________________________________________________
Reason for Medication: ___________________________________________________________________________
Special Instructions:________________________________________________________________________________
___________________________________________________________________________________________________
Side effects that might occur: ______________________________________________________________________
___________________________________________________________________________________________________
5. Medication and Dosage: _________________________________________________________________________
Frequency and Times: ____________________________________________________________________________
Reason for Medication: ___________________________________________________________________________
Special Instructions:________________________________________________________________________________
___________________________________________________________________________________________________
Side effects that might occur: ______________________________________________________________________
___________________________________________________________________________________________________
Please see reverse side
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Parent category: Medical