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:
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:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Youth Medication Form - HS
Agree & Sign