College Park United Methodist Church Child Development Centre and Primary School
Medicine Authorization Form
Child’s name________________________________________ Today’s Date_______________
Name of Medicine: _____________________________________________________________
Dates medicine is to be administered (maximum of 30 days):
______________________to _____________________
All medicine must be in its original container.
| Amount to be given | Method (ex. oral) | Time(s) to be given |
Check which one applies:
9Over the counter medication9
Prescription medication (must be labeled with the child’s name, dosage, date and prescribing physician’s name and phone number)Does your child meet the minimum age and/or weight for this medication as stated on label?
9
YES 9 NO (If no, a doctor’s note with the proper dosage must accompany this form)This form will expire 30 days from now.
Parent’s signature ______________________________________________Date______________
To be filled out by teacher:
| Date | Time | Teacher Initials | Special Notes |