Today's Date Required Child's Full Name Required Date of Birth Required Name of Medicine Required Reason medicine is needed during school hours Required Dose Required example: 1 tsp every 4 hours. Route Route Required - Select -oraltopicaleye dropsear dropsinhalationother… Enter other… Time to give medicine Required Additional instructions Required Start Date for medicine Required Stop Date for medicine Required Permission to Give Medicine Required By clicking the box, I hereby give permission and deemed competent the facility/school to administer medicine as prescribed above. I also give permission for the caregiver/teacher to contact the prescribing health professional about the administration of this medicine. I have administered at least one dose of medicine to my child without adverse effects. Parent/Guardian Name Required Phone Number Email Leave this field blank