Medication Authorization Form - St. Mark Lutheran Preschool

Parent's First and Last Name(s) *
Email Address *Share your email so that we may quickly get back to you. Your email is utilized for correspondence regarding St. Mark Lutheran Preschool only.
Phone *Example: (000)999-0000
Child's name *
Child's Teacher
Physician's Name *
Physician's Phone Number
Medication Guidelines Each and every container of medication MUST be labeled with your child’s name, teacher’s name, and the date it was delivered to school.
Medication Name *
Dosage to be administered *
Time of day to administer dosage *HHMM
Special Instructions
This authorization is effective from *
This authorization is effective until *

Doctor's note: file attachment Please upload a copy of your child’s physician authorization for prescription medications. Scan your copy by photographing the document with your smartphone, or utilizing a document scanner. We must have a digital copy to keep on file with your child’s information.