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Lowpoint-Washburn
C.U.S.D #21
21st
Century Community Learning Center Grant
After-School
Program
MEDICATION RELEASE FORM
This
form must be presented before any medication can be administered
to
your child. This includes
over-the-counter and prescribed medications.
(Aspirin,
sunscreen, bug spray, etc.) All
medication must be provided in
the
original or duplicate container with the child’s name on it, or a
container
accompanied
by the doctor’s directions.
Child’s
Full Name:_________________________________
Birth
Date:______________
Doctor:__________________
Phone:__________________
Address
of Doctor:______________________________________
Medication(s)
to be administered: ___________________________
_____________________________________________________
Times
medication is to be administered: _____________________
Please
note any additional information regarding administering
medication
to your child:
_____________________________________________________
____________________________________________________
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This
consent will be in effect beginning on
(date)________________________________
And
continue while the child is enrolled in this facility.
Signature
of Parent/ Guardian
Date
Signature
of Parent/Guardian
Date
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