Medical Administration Form – After School Club – Specialist Play Learning & Activity Team

Child's Name

Date of Birth

Dr Name

Dr Contact Number

Dr Surgery Address

Reason for Medication

Name of Medication

Storgae Requirements

Doseage

Time of administration

Parental Agreement

I agree I have check and provided in date & complete medication for my child.‎ I give permission for medicine to be given to my child in accordance with the details above.‎