Cornerstone Chapel

Youth Medication Form - HS

EACH MEDICATION MUST BE ON ITS OWN FORM. Form must be complete and medication must be in its original container to be accepted.

Youth’s Full Name:

Date of Birth:


Authorizing Parent Cell Phone:

Authorizing Parent Day Phone:

Name of Medication:

Amount/Dosage to be given:

Route of Medication:

Frequency to be administered:

Prescriber’s Name:

Prescriber's Phone:

Identify any symptoms that necessitate administration of medication:

Describe situations when medication should not be administered:

Possible side effects and action to be taken if side effects are noted (parent must supply package insert or pharmacy printout for complete list of possible side effects):

Are there any special instructions or concerns related to possible interactions with other medications the minor is receiving or concerns regarding the use of the medication as it relates to the minor’s age, allergies or any preexisting conditions?

I, the parent/legal guardian, authorize Cornerstone Chapel to administer the medication as specified to (youth’s name):

Leave this empty:

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Signature Certificate
Document name: Youth Medication Form - HS
lock iconUnique Document ID: 5cd0ce781d2be3a4219ba9f065f559e363f4fa97
Timestamp Audit
January 27, 2020 10:10 am EDTYouth Medication Form - HS Uploaded by Cornerstone Chapel - IP
January 27, 2020 10:12 am EDTHigh School - added by Cornerstone Chapel - as a CC'd Recipient Ip:
February 20, 2020 4:49 pm EDTHigh School - added by Cornerstone Chapel - as a CC'd Recipient Ip: