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Rocky Mount, NC 27804
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Parish Publications and Forms
Permission to Administer Medication (short form)
Permission to Administer Medication
Child’s Name
Name of Medication
Refrigerate
Dosage
Times to be given
Dates to be given
Parent’s Signature
Date
Monday
Tuesday
Wednesday
Thursday
Friday
Date
Time
Given by
Date
Time
Given by
Permission to Administer Medication (short form)
Last Published: April 18, 2007 8:28 AM
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