Child's Name:
    Date:
    I give permission for STS to administer the following medication to my child. I will not hold STS liable in the event of reactions or complications arising from my child receiving this medication. All medication needs to come in a labelled container from the pharmacy. Any over the counter medication needs to be in a new, unopened container.
    Name of medication:
    Reason for medication:
    Start Date:
    Finish Date:
    Times for each dose:
    Amount per dose:

    Document(s):

    Medication Log