Medication Authority Form

Medication Authority Form

In alignment with MSS OSHC's Policy 2.14 Medication Administration
Child's Name

First NameLast Name
Child's Date of Birth

DayMonthYear
Date
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: 0000-000-000.
By signing this Medication Authority Form, I give permission for educators to administer the prescribed medication in accordance with Policy 2.14 Medication Administration. I declare that this Record has been completed in conjunction with the child’s Medical Management Plan, if applicable.

I declare that I am named in the child's enrolment record as authorised to consent to administration of medication.
- Please understand that medication will only be administered as directed by the medical practitioner and only to the child whom the medication has been prescribed for. Expired medications will not be administered.
- Medication MUST be in the original container with the dispensing/chemist label attached and the child's full name.
- A separate form must be completed for each medication if more than one is required.
Name of Medication (as shown on packaging):
Is the medication self-administered by your child? (Child will take medication with no assistance outside of supervision)
The Medication is required:
Administer at:

Hour Minutes

AM/PM Option
On the following days:
Dosage of Medication to be administered:
i.e 1 tablet, 5mL, 2 puffs
Manner of administration:
Manner of administration, further details:
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Is the Medication for:

Other
Reason for medication to be administered:
Storage instructions for medication:
Time & date last administered:
Expiry/used by date:
Prescribing doctor/medical practitioner's name:
Contact details for doctor/medical practitioner:
I confirm that the medication provided to MSS OSHC:
I give consent for MSS OSHC to, if applicable,:
Parent/Guardian Signature:
Date

DayMonthYear
Date

MSS OSHC to Complete ONLY:

Rows	Service Storage Location of Medication:	Action Plan acquired?:	Risk Minimisation Plan?:	Recorded on Daily Run Sheet?:
Service Information:

Name of Educator receiving medication:

First NameLast Name
Date Medication was received:

DayMonthYear
Date
Signature of Educator receiving medication:
- Details for student self-administration of medication:
  
  In alignment with MSS OSHC's Policy 2.14 Medication Administration and Education and Care Services National Regulations 96 Self-administration of medication.
- Child's Name
  
  First NameLast Name
- Child's Date of Birth
  
  DayMonthYear
  Date
- By ticking these options, I confirm that:
- Parent/Guardian Signature:
- Date
  
  DayMonthYear
  Date
- Should be Empty:

Medication Authority Form

Details for student self-administration of medication: