Medication Authorization Consent- DHI/ PAC/ RSPO & Camp

Please list all medications:

Completed By:*
Date*

MonthDayYear
Date
I Authorize Noble staff to administer the medication listed above. I understand that the medicaiton must be provided in the original lableled prescription container, properly stored according to directions, separate from non-medical items, and in sufficient quantity to last the length of the shift(s).
Signature of Parent/ Guardian:*

Clear
Medication Authorization Consent
Medication to be given, including time and dosage:*
I authorize Noble staff to administer the prescribed medication listed below to First Name* Last Name*

in accordance with written orders of the prescribing physician. I understand that a written order from the physician and the properly labeled pharmacy container must be provided in order for the medication to be given.
Signature of Parent/ Legal Guardian*

Clear
Legal Guardian?

NoYes
Should be Empty: