Common use of Authorization to Administer Medication Clause in Contracts

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. 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: