Medication Authorization Form (Youth Programs)

Download a PDF version. Return completed forms to ksantor@burlingtonvt.gov.

One form per medication. Medication cannot be administered until the information below is completed
Child's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Medication Information
Name 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 Information
Prescribing Health Professionals Name
Prescribers Phone Number
Name of Pharmacy
Pharmacy phone number
Permission to Give Medicine
I 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

Medication Information