Fundamentals Child Development Center, LLC

Authorization for the Administration
of Medicine Form

Email* First Name* Last Name* Name of Child* Date of Birth* Today's Date* Medication Name* Dosage/Time*

Method* Specific Instructions for Medication Administration* Administration Start Date* Stop Date* Is this medication to be self administered by child?*

Relevant Side Effects of Medication* Plan of Management for Side Effects* Prescriber's Name* Phone* Date*

Parent/Guardian Authorization | I request that medication be administered to my child as described and directed above and attest that I have administered at least one dose of the medication to my child without adverse effects.* Yes* I request that medication be self administered to my child as directed above.* Yes By checking this box marked Yes below I certify that I am in consent with all information submitted on this form* Yes* Door Code*

Authorization for the Administration of Medicine Form

Authorization for the Administration
of Medicine Form