††††††††††††††††††††††††††††††††††††††††††††††††† Prescription Medication

 

 

 

Childís Name:____________________________________________________________

 

 

Childís Teachers:__________________________________________________________

 

 

Parentís Signature:________________________________________________________

 

 

Name of Medication:____________________††† Name of Medication:________________

 

Reason for Medication:__________________†††† Reason for Medication:______________

 

_____________________________________†† ††_________________________________

 

Dates for Medication:___________________††††† Dates for Medication:________________

 

Dosage:______________________________††††† Dosage:___________________________

 

 

Staff††††††††††† Time†††††††††† Date†††††††††† Amount ††††††Staff†††††††††††† Time†††††††††† Date††††††† Amount

____________________________________†††††† ___________________________________

 

____________________________________†††††† ___________________________________

 

____________________________________†††††___________________________________

 

____________________________________†††††† ___________________________________

 

____________________________________†††††† ___________________________________

 

____________________________________†††††† ___________________________________