Short Term Medication Administration Form
For Prescription and Non-prescription Medications

Medication Policy Statement:
All prescription medications require a label attached to the medication that includes name of medication, dosage, and route of dosage. It also should give a length of time for the prescription to be given.
Physician authorization is designated by the prescription.
All medication will be kept locked up in the academy office.

This Medication Authorization form must be completed on or before the first day the child is to receive the medication. This form must be updated based on the type of medication or as required by law. This form will be kept in the academy office with the medication.

Prescription or Non-Prescription Medication authorization for (child's name) *
Your answer
The OVCA nurse or Medical Administration Trained (MAT) staff at Ocean View Christian Academy has my permission to administer the following medication: *
Your answer
Dosage *
Your answer
Times to be administered *
Your answer
Special instructions (if any)
Your answer
This authorization will expire on *
MM
/
DD
/
YYYY
Parent or Guardian (electronic) Signature
Your answer
By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
Your answer
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