Emergency Contact/Medication Form

Exact Location of Parents:

Location Phone Number:

Other Contact Name:

Other Contact Phone Number:

Allergies or special Conditions:

I authorize the provider to give my child, children or family member medication:

Yes

Medication Instructions:

Please include the specifs of the medication dosage and intervals you are requesting the provider gives:

Medication Name:

Times:

Intervals:

Dosage:

Pediatrician/Doctor:

Number:

I recognize the provider is not medically licensed and is administering this medication at my request and for my convenience.

Agree

Disagree

Parent Signature:

Provider Name: