KENTUCKY STATE UNIVERSITY Cooperative Extension Program 4-H Youth Development
Medical Information and Authorization PARENT/GUARDIAN AUTHORIZATION AND RELEASE
PARTICIPANTNAME:___
SECTION 5. PERMISSION TO ADMINISTER MEDICATIONS
Medication #1
Medication Name: ___
Dosage: ___
Expiration Date: ___ / ___ / ___
Refrigerate: ☐ Yes ☐ No
Times: ___ AM/PM ___ AM/PM ___ AM/PM ___ AM/PM
Special Instructions: ___
Possible Reactions: ___
Medication #2
Medication Name: ___
Dosage: ___
Expiration Date: ___ / ___ / ___
Refrigerate: ☐ Yes ☐ No
Times: ___ AM/PM ___ AM/PM ___ AM/PM ___ AM/PM
Special Instructions: ___
Possible Reactions: ___
Medication #3 (if needed)
Medication Name: ___
Dosage: ___
Expiration Date: ___ / ___ / ___
Refrigerate: ☐ Yes ☐ No
Times: ___ AM/PM ___ AM/PM ___ AM/PM ___ AM/PM
Special Instructions: ___
Possible Reactions: ___