Medication Authorization (Karuizawa)

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Email *

I agree to fill out One form per Child *

I agree

Required

【Child】Surname 苗字 (eg: Wang)(例: Tanaka) *

【Child】Given name 名前 (eg: Xincheng)(例: Akiko) *

【Child】Date of Birth (生年月日) *

YYYY

Class *

Preschool

I understand that medication must be labelled clearly. 間違えを防ぐ為、薬の袋やボトルにラベル等貼る必要があることを理解しました。 *

I understand (理解しました)

Required

I understand that teachers cannot administer over-the-counter medicine.

市販の薬は学校では投薬出来ないことを理解しました。 *

I understand (理解しました)

Required

Details on how to administer medication (Please include (1) Name of Medicine (2) Dosage (3) Frequency (4) Timing to administer medicine （投薬詳細をご記入ください)以下をご記入ください(1) 薬の名前 (2) 量 (3) 頻度 (4) 投薬のタイミング *

This form is filled by (フォームの記入者) *

Mother (お母さま)

Father (お父さま）

Full Name of the Above Person (上記の方のフルネーム） *

Mobile Number of the Above Person (上記の方の携帯番号） *

A copy of your responses will be emailed to the address you provided.

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