PERMISSION FORM
FOR
ADMINSTRATION OF MEDICATION






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:____________________