Medication Authorization
Lifespan Montessori teachers are only authorized to dispense prescription medications authorized by a healthcare provider.  This authorization must be filled out entirely.  If the prescription number is not located on the bottle, please attach the authorization with the medication.  If any of this information is missing, we will be unable to dispense the medication.
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Child's Full Name *
Name of Medication *
Prescription Number *
All medications must have a prescription number.  Over the counter medications require a doctor's note.  
Amount of medication to be given *
How is the medication dispensed?
Ex. Syringe, cup, spoon, vial, etc.
Time of day to dispense medication *
We cannot give medication on an "as needed" basis, nor can we interpret symptoms.  You must give specific times.
시간
:
2nd time of day to dispense medication
Optional
시간
:
3rd time of day to dispense medication
Optional
시간
:
Start Date *
YYYY
/
MM
/
DD
End Date *
YYYY
/
MM
/
DD
Additional Information
Please include any adverse side effects that your child may experience while taking this medication.  
Full name of person filling out this form *
Relationship to Child *
I understand that the staff at Lifespan Montessori will be unable to dispense medication on an "as needed" basis or medications without a prescription. *
I understand that I must provide written notice if I wish to stop medication prior to the listed end date. *
I understand that medications may not be placed in the child's cubby.  They should be handed directly to the office administrator. *
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