Permission to Administor Medication

Child's Name *

Name of child receiving medication

Medication *

The medication to be administered

Dose *

The amount to be given

Times to be taken *

Ho often should to medicine be administered

Start Date *

Day

Month

Year

Date to start administering medication

End Date

Day

Month

Year

Date to finish administering medication. Leave blank if medication will be on-going

How should the medicine be administered *

How the medicine be administered? Orally, topically or injection?

Special care instructions for medication

For example, should the medication be refrigerated or locked away?

Parent's Name *

Name of authorising parent

Parent's Email *

Parent's Mobile Number *

Notes

Any further details we need to know

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