Medical Authorisation
Please complete this form so we can care for your child safely and confidently.
PARENT/ GUARDIAN INFORMATION
*
First Name
Last Name
Mobile Number
Enter the mobile number of the person who will be on site at the event.
Format: (000) 000-0000.
Emergency Contact
*
Emergency Contact Number
*
CHILD INFORMATION
Rows
Child One
Child Two
Child Three
Name
Age
Does your child require medication to be administered during care?
*
Yes
No
Child Name
*
Child Date of Birth
*
-
Month
-
Day
Year
Date
Date to be administered
*
-
Month
-
Day
Year
Date
Times to be administered
*
Times and frequency
Reason for medication
*
Known side effects
*
Doseage
*
Method of administration (oral, topical, liquid, tablet, etc.)
*
Parent/ Guardian Authorisation
*
First Name
Last Name
By signing below, I confirm that the information provided is complete and accurate.
*
Your signature confirms you acknowledge and agree to our Terms & Conditions.
Date of authorisation
*
-
Month
-
Day
Year
Date
Print
Submit
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