Authorization to Administer Medication. I hereby authorize the program staff to administer my child the below-listed medication. I understand that medication, whether over-the-counter or prescription, should be kept in original containers. Prescription medication containers should bear the pharmacy label, date of filling, pharmacy name and address, patient name, name of prescribing practitioner, name of prescribed medication, directions for use, storage and cautionary statements, as originally appeared on the container. When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication cannot be returned, it shall be destroyed. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program. I agree to notify the program of any changes in the above information in a timely and reasonable manner. Medications Dosage Instructions: Storage, Frequency, duration Quantity Received Special Instructions Name of Participant: Date: Signature of Parent or Guardian: Parent or Guardian Name:
Authorization to Administer Medication. We give permission for Chaminade to administer the prescription and over-the-counter medications specifically set forth above to our minor child at the time and manner indicated during the activity period described above. In consideration for dispensing medication to our child, we hereby, for ourselves, our minor child, and our heirs, executor assigns and personal representatives, waive and release any and all rights and claims for damages we now, or may hereafter have, whether now known or unknown on account of any personal injury to us or our child, in connection with the administration of the medications listed above, including injuries caused by or contributed to by the negligence of Chaminade.
Authorization to Administer Medication. Please administer the following medications as needed: *Please note the dosage and the reason for administration of the medication. Signature Date Child’s Name: DOB: Authorization to Release or Obtain Information I hereby authorize Children’s Therapy TEAM (DBA Children’s Therapy TEAM) to release or obtain my child’s individually identifiable information, including contact information, information about physical or mental health, information about health care services, information about education services and information about payment for services under the circumstances described below. Purpose (check one or more) ☐ at the request of the parent/guardian ☐ for Health Care Services Release Disclosure TO/FROM (circle one or both) Disclosure TO/FROM (circle one or both) *Type of information to be disclosed in oral or written form: *NOTE: If this authorization is used for psychotherapy notes, it may not be used for any other type of information. I understand that: This authorization must be filled out completely. A copy is as valid as the original. Children’s Therapy TEAM will not refuse to provide health care services to me, based on my refusal to authorize the use or disclosure of my child’s personal health information for purposes unrelated to those health care services. I may revoke this authorization at any time by notifying Children’s Therapy TEAM in writing, but if I do, it won’t affect any actions Children’s Therapy TEAM took in reliance of this authorization before I revoked it. Once information is released to a third party according to this authorization, Children’s Therapy TEAM cannot prevent its re-disclosure. This authorization does not limit the ability of Children’s Therapy TEAM to use or disclose my child’s health information as otherwise permitted by state and federal law. PRINT Parent/Legal Guardian’s Name: Parent/Legal Guardian’s Signature: Date: Expiration Date 1 year from date signed, unless an earlier date is provided here: You are entitled to a copy of this authorization form. Child’s Name: Date of Birth: Today’s Date: Evaluation Date: Parent/Guardians Names: Employer(s): Parents’ Dates of Birth: Address: City: State: Zip Code: Name of Emergency Contact (other than the parent): Emergency Contact Phone Number: Communication Preferences: Please mark phone preferences as: (1) use first, (2) use as back-up, (X) do not use Home Phone Number
