Administering Medications To A Minor - Girl Scouts Of Western Washington

Download a blank fillable Administering Medications To A Minor - Girl Scouts Of Western Washington in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Administering Medications To A Minor - Girl Scouts Of Western Washington with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.


Administering Medications to a Minor
Written authorization and instruction from medical provider in regard to administering medications
I am familiar with the medication condition of__________________________ [name of Girl Scout], who is a patient
of________________________ [name of office or clinic]. I understand that the purpose of this form is to allow a Girl Scouts of Western
Washington volunteer to administer medication to the above named girl, and believe that he or she should be able to follow the
instructions listed below without any further training and without detriment to the Girl Scout. ______________________ [name of Girl
Scout] has the condition(s) set forth below that require that she take medication that has been prescribed by this clinic or by me. The
volunteer who administers the medication should keep it in its original, marked container, should store it out of reach of other children,
and should give the Girl Scout the medication in the dosage and according to the schedule set forth below:
When and how often
Special Storage Requirements
Medical Condition
Name of Medication
dose is administered
(i.e. refrigerator, etc.)
Are there any OTC medications that are contraindicated for this Girl Scout?
If Yes, please list below:
If the volunteer has any questions or observes the Girl Scout having any of the following symptoms, the volunteer should contact this
office or another qualified medical provider immediately.
Signature of Physician:
Name (Print):
Phone Number:
Emergency Number:


00 votes

Related Articles

Related forms

Related Categories

Parent category: Business