MEDICATION PERMISSION 



Child’s Name____________________________     Date __________________

Name of Medication ______________________________________________	

Date Start  ________________     Date Stop     ________________________

Time(s)  to be administered:

_______________________________________________________________

Dosage to be given _________________________________________________



Permission granted by   _______________________________  Date_________
					Parents Signature 



---------------------------------------------------------------------------------------------------------
MEDICATION PERMISSION 



Child’s Name____________________________     Date __________________

Name of Medication ______________________________________________	

Date Start  ________________     Date Stop     ________________________

Time(s)  to be administered:

_______________________________________________________________

Dosage to be given _________________________________________________



Permission granted by   _______________________________  Date_________
					Parents Signature