Administration of Medication Form

Form
Medication Administration Form

Please complete and submit prior to arriving at the centre. Please provide your child's medication in a labeled Ziploc bag to the Check-In Supervisor. Failure to do so will result in having the medication refused upon arrival. Thank you.
Date*

MonthDayYear
Date
Child's Full Name*

First NameLast Name
Parent Contact Number*

Area CodePhone Number
Name of Medication (found on the prescription bottle)*
Prescription Number (RX Number found on the prescription label)
DIN Number (DIN Number found on the medication label)
Please administer this medication according to:*

Doctor's Instructions found on the prescription labelAccording to the instructions on the medication label (for use with over the counter medications)
Time of first daily dosage to be administered

:HourMinutesAM/PM Option
Time of second daily dosage to be administered

:HourMinutesAM/PM Option
Time of third daily dosage to be administered

:HourMinutesAM/PM Option
Time of fourth daily dosage to be administered

:HourMinutesAM/PM Option
Medication Start Date
Medication End Date
Parent Comments
I Parent's Full Name* give The Kinder Garden Children's Centre permission to administer the above medication to my childChild's Full Name* as directed and when in attendance until the above noted medication end date.
Parent Signature*

Clear
Should be Empty:

Form