Sweden/Clarkson Recreation

 

Child’s Name;___________________________________________________ Grade Just Completed________

 

Address:________________________________________________ City:__________________

 

Zip: _____________  Phone: __________________________ Emergency Phone: ______________________

 

 

 

1. Please list any medical conditions: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

2. Authorization for dispensing medication:

 

Medication Name: ________________________________________________Prescription # ______________

 

Dosage: __________________  Time to be given: ____________________________

 

Instructions: ________________________________________________________________________________________________________________________________________________________________________________________

 

Prescribers Name: ___________________________________________________________________________

 

License Number: _____________________________________________________________________________

 

Parent/Guardian  Signature: __________________________________________________________

 

Date: _______________________