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