Trinity Preschool Medication Form
Parent's Full Name
Child's Full Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Child's Classroom
My child needs
(Medication #1)
from
(start date to finish date or as-needed)
.
Medication #1
Yes
No
Child's Full Name
In Original Container
Name of Medication
Name of Physician
Schedule of Administration
Amount Given per Dose
Pharmacy Name
Over the Counter Medicine
List symptoms / illness:
My child needs
(Medication #1)
from
(start date to finish date or as-needed)
.
Medication #2
Yes
No
Child's Full Name
In Original Container
Name of Medication
Name of Physician
Schedule of Administration
Amount Given per Dose
Pharmacy Name
Over the Counter Medicine
List symptoms / illness:
Parent or Guardian Signature
Clear
Date
Submit
Should be Empty: