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 *

Month Day Year
Date
Child's Full Name *

First Name Last Name
Parent Contact Number *

Area Code Phone 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 label According to the instructions on the medication label (for use with over the counter medications)
Time of first daily dosage to be administered *

: Hour Minutes AM/PM Option
Time of second daily dosage to be administered

: Hour Minutes AM/PM Option
Time of third daily dosage to be administered

: Hour Minutes AM/PM Option
Time of fourth daily dosage to be administered

: Hour Minutes AM/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