Dispensing of Medication Form

This form allows Maywood Volunteers or On-Site Medical Personnel to dispense the following medication/s to your child(ren) during the activity dates listed below. All medication MUST be given to us in its original packaging per state law.

Parent First and Last Name(s)

Email Address

Dates of Activity

Child #1

Child First and Last Name

Name of Each Medication

Dosage of Each Medication

Time of Day for Administering Each Medication

Child #2

Child First and Last Name

Name of Each Medication

Dosage of Each Medication

Time of Day for Administering Each Medication

Child #3

Child First and Last Name

Name of Each Medication

Dosage of Each Medication

Time of Day for Administering Each Medication

Child #4

Child First and Last Name

Name of Each Medication

Dosage of Each Medication

Time of Day for Administering Each Medication

Enter Code

Submit

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