Beaufort-Jasper Eoc Head Start

Physician's Authorization to Administer Medication

Child's Last Name:*

Child's Middle Name:

Child's First Name:*

What program option are you registering for?*

Center:*

Medication dosage, amount and frequency:

Administer until

Precautions, side effects, possible adverse reactions and actions indicated:

Physical condition for which medication is prescribed:

Directions for procedures, or other helpful information:

Physician’s Name:

Address Line 1:

Address Line 2:

Phone:

Date:

Medication Administration Consent

I hereby request and give permission to Beaufort Jasper EOC Head Start to administer to my child, the following medication (s) as instructed and prescribed by the health provider listed above. Medication will be furnished by parent/guardian in a container properly labeled by a pharmacist, and in the original container. All medications must have child's name, medication dispensed, dose prescribed and time it is to be given. I hereby give my permission for my child to receive medication during school hours. This medication has been prescribed by a licensed physician. I hereby release Beaufort Jasper EOC Head Start and their staff from all liability that may result from my child taking the prescribed medication. I give permission for the Beaufort Jasper Head Start Staff to communicate with the Medical Provider concerning diagnosed medical condition related to above prescribed medication.

Name of Medication and Prescription Number:

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