administration of medication - permission form

As the parent and/or guardian for the name of child above, give permission for a BGCB staff member to administer the following prescription or non-prescription medication(s):


Just in case you need to put more than 2 medications, please do contact our office. See contact information down below.

Medication #1

Medication #2

Your signature indicates that you understand:

• All prescribed medications will be administered only in accordance with the pharmacy label.

• All prescribed and non-prescribed mediation must be in the original packaging from the pharmacy.

• Staff members make every effort possible to ensure that medication is taken by the child. If the child refuses to take the medication, or a dosage is missed, the parent/guardian will be contacted immediately.

• Any changes made to the medication’s dosage, medication name, and/or prescribing doctor requires a new Administration of Medication Form to be completed.

• BGC Battlefords reserves the right to refuse to administer medication in situations that the administration of the medication poses a risk to the child, youth, BGCB staff member or organization.