Authorization To Administer Medication

Authorization to Administer Medication to Minor

Child Name: _________________________________

Birthdate: _________________________________

Guardian Name: _________________________________

Facility Name: _________________________________

Address: _________________________________

I, ___________________________, the legal guardian of the child named above, hereby authorize certified employees of _________________________________ to administer the following medication(s) to said child:

Medication: ___________________ Dose: ____________ Time(s): __________________

Medication: ___________________ Dose: ____________ Time(s): __________________

Medication: ___________________ Dose: ____________ Time(s): __________________

Medication: ___________________ Dose: ____________ Time(s): __________________

This authorization shall remain in effect from __________ to __________.

Guardian  _________________________ Date __________

Employee _________________________ Date __________

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