I hereby certify that it is necessary for ______________________________________(full name of child)
to be given the following medication.Name of medication:_________________________________________________________________
Purpose of medication:______________________________________________________________
Dosage to be given:_________________________________________________________________
Time(s) of administration:__________________________________________________________
Side effects:_______________________________________________________________________
Special Instructions:_______________________________________________________________
Doctor's name:________________________________ Phone Number:________________________
Signature:____________________________ Relationship to Child:____________________