Medication Usage Authorization Form
This form must be submitted before or on the
day of departure
for each event.
Name of Student taking Medication
*
Name of Medication:
*
Dates Medicine to Be Taken
*
Times/Day
*
Time(s) of Day
Morning
Afternoon
Evening
Night
With Meals
Dosage:
*
Name of Medication:
Dates Med. to Be Taken
Times/Day
Time(s) of Day
Morning
Afternoon
Evening
Night
With Meals
Dosage:
Name of Medication:
Dates Med. to Be Taken
Times/Day
Time(s) of Day
Morning
Afternoon
Evening
Night
With Meals
Dosage:
Name of Medication:
Dates Med. to Be Taken
Times/Day
Time(s) of Day
Morning
Afternoon
Evening
Night
With Meals
Dosage:
Name of Medication:
Dates Med. to Be Taken
Times/Day
Time(s) of Day
Morning
Afternoon
Evening
Night
With Meals
Dosage:
Additional Comments:
Parental/Guardian Signature
*
Date
*
/
Month
/
Day
Year
Date Picker Icon
Submit
Should be Empty: