Fillable Administering Medications To A Minor - Girl Scouts Of Western Washington printable pdf download

Administering Medications To A Minor - Girl Scouts Of Western Washington

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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

Dosage

dose is administered

(i.e. refrigerator, etc.)

Are there any OTC medications that are contraindicated for this Girl Scout?

Yes

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:

Date:

Name (Print):

Title:

Phone Number:

Emergency Number:

Administering Medications To A Minor - Girl Scouts Of Western Washington

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