Medication Usage Authorization Form

Medication Usage Authorization Form
Please send ALL medications (prescription and/or over the counter medication) with your child that they will need to take while at the ECC Student event/retreat
This form must be submitted before or on the day of departure for each ECC Student event.
Name of Student taking Medication*
Name of Medication:*
Dates Medicine to Be Taken*
Times/Day*
Time(s) of Day
Dosage:*
Name of Medication:
Dates Med. to Be Taken
Times/Day
Time(s) of Day
Dosage:
Name of Medication:
Dates Med. to Be Taken
Times/Day
Time(s) of Day
Dosage:
Name of Medication:
Dates Med. to Be Taken
Times/Day
Time(s) of Day
Dosage:
Name of Medication:
Dates Med. to Be Taken
Times/Day
Time(s) of Day
Dosage:
Additional Comments:
Parental/Guardian Signature*
Date*

MonthDayYear
Should be Empty: