Administration of Medication - Permission Form - Battlefords Boys & Girls Club

administration of medication - permission form

I (Parent/Guardian Name): *

First

Last

of (Child's Name): *

First

Middle

Last

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):

MEDICAL INFORMATION

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

Medication #1

Patient name on presciption bottle: *

First

Last

Name of medication: *

Prescribed dosage: *

Time(s) or situation(s) to be administered: *

Possible side effects: *

Name of Physician: *

First

Last

Phone number of Physician: *

Medication #2

Patient name on presciption bottle:

First

Last

Name of medication:

Prescribed dosage:

Time(s) or situation(s) to be administered:

Possible side effects:

Name of Physician:

First

Last

Phone number of Physician:

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.

Parent/Guardian Signature - DATE: *

Parent/Guardian - NAME: *

First

Last

Office Staff - DATE:

Office Staff -NAME:

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Last

Executive Director - DATE:

Date

Time

Executive Director - NAME:

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Last