Prescription Medication

Child’s Name:____________________________________________________________

Child’s Teachers:__________________________________________________________

Parent’s Signature:________________________________________________________

Name of Medication:____________________ Name of Medication:________________

Reason for Medication:__________________ Reason for Medication:______________

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Dates for Medication:___________________ Dates for Medication:________________

Dosage:______________________________ Dosage:___________________________

Staff Time Date Amount Staff Time Date Amount

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