Language
English (US)
Chinese
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
*
Medications:
*
Reasons for Medication
Start Date
-
Day
-
Month
Year
Date
Until Date
*
-
Day
-
Month
Year
Date
Total types of medications:
Submit
Should be Empty: