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Authorization for the Administration of Medication

Parents/Guardians: Please fill out this document prior to registration day.
Name of Child(Required)
MM slash DD slash YYYY

Medication Information

Controlled Drug?(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
May this medication be self-administered by the child?(Required)
Known food or drug allergies?(Required)
Reactions to?(Required)
Interactions with?(Required)

Parent/Guardian Consent

Name of Parent/Guardian authorizing administration of medication as described and directed above(Required)
Relationship to child(Required)
Address(Required)
Parent / Guardian Authorization