Medication Authorization Form (Youth Programs) Download a PDF version. Return completed forms to ksantor@burlingtonvt.gov. Medication Authorization Form One form per medication. Medication cannot be administered until the information below is completedChild's Name* First Last Date of Birth* MM slash DD slash YYYY Medication InformationName of Medication* Dose Details* Delivery/Route Details* Does the medicine need to be refrigerated Yes No Reason for medication* Date to start medication* MM slash DD slash YYYY Date to stop medication* MM slash DD slash YYYY Time(s) of medication administration* Additional instructions Known side effects of medicine Plan of management of side effects Child allergies Prescriber’s InformationPrescribing Health Professionals Name Prescribers Phone Number Name of Pharmacy Pharmacy phone number Permission to Give MedicineI hereby give permission for the camp program to administer medicine as prescribed above. I also give permission for BPRW staff 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 or Guardian Name First Last Phone