Medication Permission Form

Medication Permission Form

Authorize Start Bright staff to administer medication to your child as specified below.
Child's First and Last Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian's First and Last Name

First NameLast Name
Parent/Guardian's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Medication
Reason for Medication
Dosage (include strength)
Time(s) to Administer
Duration (Start and End Dates)
Administration and Storage Instructions (if any):
Permission to Administer. By signing below, you authorize Start Bright staff to administer the above medication to your child as specified.
Signature of Parent/Guardian
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: