Breakthru® Sponsorship Application Form

Breakthru® Prescription Medication Log

rel 2024
Application for Fees Sponsorship / Concession
Name of Child*
As per I.C. / Passport
Class/Program*
Authorization (please tick):

I give my child's Class Facilitator to administer the following medication tomy child. I will not hold my provider liable in the evet of reactions or complicationsarising from my child receiving this medication.
Signature of Parent as Confirmation*

Clear
Medications:*
Reasons for Medication
Start Date

DayMonthYear
Date
Until Date*

DayMonthYear
Date
Total types of medications:
Should be Empty:

Breakthru® Prescription Medication Log