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: ___