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Youth Medication Form - MS

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:

Allergies:

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:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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December 28, 2019 9:52 am EST

Youth Medication Form - MS Uploaded by Cornerstone Chapel - edocs@cornerstonechapel.net IP 174.196.134.180

December 28, 2019 9:55 am EST

Middle School - middleschool@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 50.225.112.66

December 28, 2019 10:08 am EST

Middle School - middleschool@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 50.225.112.66

February 20, 2020 4:49 pm EST

Middle School - middleschool@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 174.196.134.180