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.
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)*

YesNo
The Medication is required:*
Administer at:*

Hour Minutes

AM/PM Option
On the following days:*

MondayTuesdayWednesdayThursdayFriday
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:*

AsthmaAnaphylaxisDiabetesEpilepsyOther
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:*

is authorised by a registered medical practitioner (e.g. has been prescribed by a doctor, dentist, optometrist, pharmacist or nurse practitioner).is in the original dispensed container with intact packaging.has the child's full name and registered medical practitioner's name on the pharmacy label.
I give consent for MSS OSHC to, if applicable,:

liase with school staff regarding the last administration of medication to my child during school periods.
Parent/Guardian Signature:*

Clear
Date*

DayMonthYear
Date

MSS OSHC to Complete ONLY:

	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:

Clear

Medication Authority Form

Details for student self-administration of medication: