BEFORE
& AFTER SCHOOL CARE (BASC) MEDICATION
AUTHORIZATION FORM
MEDICATION NAME: _____________________________________ PRESCRIPTION: YES NO
DOCTOR’S NAME:
_______________________________________TELEPHONE: _________________
I REQUEST THAT MY
CHILD BE GIVEN THIS DOSE AS INDICATED ON THE PRESCIPTION LABEL,
OR BY MY REQUEST IF
IT IS A NON-PRESCRIPTION ITEM (Fill in specific dose amount):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
THIS MEDICATION SHALL
BE ADMINISTERED AT (Name the precise time when the medication is to be given
or
conditions/symptoms when non-prescription medication is to be given):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
THIS WAIVER IS
ACCOMPIANIED BY A NOTE FROM THE PHYSICIAN AND A NOTE FROM ME SPECIFICALLY
REQUESTING THAT THE PRESCRIBED DOSAGE OF
MEDICATION OR OVER THE COUNTER MEDICATION
(name
of medication) ____________________________________________ BE ADMINISTERED AT
THE PRESCRIBED
OR ALLOWED TIME (which is) _____________________.
PRINT PARENT’S NAME ______________________________________________________________
PARENT SIGNATURE
________________________________________________________________
DATE _____________