medication_perm

Medication Permission
Generator

Important: This is a generic form. Please be sure it meets your organizations guidelines before using it.

Parents or guardians of girls who take prescribed medications (for example, allergy pills) should inform leaders in advance.
Over-the-counter or prescribed medications should be in the original container and administered in the prescribed dosage by or in the presence of the responsible adult as per the written permission of a custodial parent, a guardian, or a physician.
Medications, including over-the-counter products, should never be given without prior written permission from a girl’s custodial parent or guardian.
Some girls may need to carry and administer their own medications, such as bronchial inhalers/epi pens. Leaders should be notified of such a circumstance as well.
One form is required for each medication.

ALL MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER!

Girl’s Name:

Name of Medication:

Purpose of Medication:

If Prescription note #:

Prescribing Dr.:

Prescribing Dr. Phone:

Date

Time

Dosage

1st Dose:

2nd Dose:

3rd Dose:

4th Dose:

5th Dose:

If more doses are needed, continue on another form. This is Form of for this medication.

Directions for Administering:

I HEREBY GIVE PERMISSION FOR AN ADULT IN LEADERSHIP CAPACITY OR A FIRST AIDER TO ADMINISTER THIS MEDICATION ACCORDING TO THE ABOVE DIRECTIONS. NO MEDICATION WILL BE ADMINISTERED WITHOUT SPECIFIC INSTRUCTIONS FROM A PARENT OR GUARDIAN.

Please acknowledge, by signing, that you have discussed medication administrations and given permission for the administration of noted prescriptions.

Parent/Guardian:

Sign after printing

Date:

Date when signing

Day Phone:

Evening Phone:

Group Leader:

Have Leader Sign

Date:

Date when signing