Medication Permission Slip
I, ___________________________, parent of ________________________________ do hereby give my permission for Rosebud
Preschool Staff give the following medicines to my child.
_____________________ _____________________ ____________________________________
Name of Medicine Dose to be Given Time/s to be given
_____________________ ______________________ _____________________________________
Name of Medicine Dose to be Given Time/s to be given
_____________________ _______________________ _____________________________________
Name of Medicine Dose to be Given Time/s to be given
_____________________ _______________________ _____________________________________
Name of Medicine Dose to be given Time to be given
_____________________________________________
Name of Parent or Guardian
_____________________________
Date
I, ___________________________, parent of ________________________________ do hereby give my permission for Rosebud
Preschool Staff give the following medicines to my child.
_____________________ _____________________ ____________________________________
Name of Medicine Dose to be Given Time/s to be given
_____________________ ______________________ _____________________________________
Name of Medicine Dose to be Given Time/s to be given
_____________________ _______________________ _____________________________________
Name of Medicine Dose to be Given Time/s to be given
_____________________ _______________________ _____________________________________
Name of Medicine Dose to be given Time to be given
_____________________________________________
Name of Parent or Guardian
_____________________________
Date
To download a copy of this form:
| medication_permission_slip.doc |