Permission to Administer Medication (long form)
Permission to Administer Medication
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Child’s Name
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Name of Medication
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Dosage
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Refrigerate :
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please circle Yes or No
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Times to be given
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Dates to be given
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-------------------------------------------------------------------------To be filled out by Staff --------------------------------------------------------------------
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Time Given___________________
Signature_____________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
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Time Given___________________
Signature_____________________
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Last Published: April 18, 2007 8:29 AM
