Club J Authorization to Dispense Medication Childs Full Name: Name of Parent filling out form: Name of Medication: Dosage: Prescription Number: Time Medication is to be given: Amount of Medication to be given: Dates to be given: Parents - - 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Child’s Full Name in the designated field. This ensures that the medication is accurately associated with the correct child.
3. Next, fill in the Name of Parent filling out the form. This identifies who is responsible for authorizing medication administration.
4. In the Name of Medication field, specify the exact medication being dispensed. Accuracy here is crucial for safety.
5. Enter the Dosage as prescribed by a healthcare professional. This should match what is indicated on the prescription label.
6. Provide the Prescription Number, which helps track and verify the medication details.
7. Indicate the Time Medication is to be given, ensuring clarity on when doses should be administered.
8. Fill in the Amount of Medication to be given, aligning with dosage instructions.
9. List Dates to be given for when this medication should be administered, providing a clear schedule for caregivers.
10. Finally, sign and date at the bottom of the form to confirm your authorization before submitting it for processing.

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