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LVW Medications Permissions Form
Please read the
LVW Permissions Information
before completing this form.
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* Indicates required question
Email
*
Your email
Please list the Parent/Guardian who is filling out this form. Provide your First and Last name.
*
Your answer
Please list the LVW member for whom you are filling out this form - First and Last Name
*
Your answer
I (the Parent/Guardian) give permission for the LVW Medical Volunteer(s) to administer over-the-counter medications listed in Table 1 as described in the LVW Permissions Information.
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Yes - I give my parental/guardian permission for the LVW Medical Volunteer(s) to administer OTC medications as described in the form.
No - I do not give my parental/guardian permission for the LVW Medical Volunteer(s) to administer OTC medications as described in the form.
If "No" in the previous question, please explain here.
Your answer
If your son/daughter has prescription medications that he/she will be handling on their own, please list them here.
Your answer
My son/daughter has emergency and/or life saving prescription medications as described in Table 2
*
Yes
No
If YES to Table 2 medications as indicated above, please list them here, as well as your preference for how they are administered to your child.
Your answer
A copy of your responses will be emailed to the address you provided.
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