Medication Consent Form

Medication Consent Form
Date
Child's Name

First NameLast Name
Child's Classroom
Name of Medication
Is the medication ...

prescriptionover the counter
Does the medication require refrigeration ?

YesNo
For what condition is the child taking this medication?
At what times should medication be administered? (We may only administer medication at the times designated on the prescription itself).
Medication start date blanks . And end on this date blank .
Please list the instructions for administering this medication (i.e. dosage, frequency, time of day, with food, etc.)
Please note: Over the counter medications will not be administered for more than 5 days without a note from the physician. All medications must:

- be in the original container
- be prescribed to the child it is being administered to
- not be expired
- be administered according to instructions
I hereby give permission for staff at The Wonder Years Academy to administer the above medication(s) to my child according to practitioner's and/or my instructions.

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Parent's Name

First NameLast Name
Should be Empty: