Medication Permission Form
Authorize Start Bright to administer medication to your child as specified below.
Child's First and Last Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Parent/Guardian's Name
First Name
Last Name
Parent/Guardian's Phone Number
Please enter a valid phone number.
Name of Medication
Dosage (Include Strength)
Time(s) to Administer
Duration (Start and End Dates)
Reason for Medication
Administration Instructions (if any)
Permission to Administer. By signing below, you authorize Start Bright to administer the above medication as specified.
Signature of Parent/Guardian
Date of Signature
-
Month
-
Day
Year
Date
Submit Permission
Submit Permission
Should be Empty: