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After School (ASK) Summer / Fall Break / Spring Break / Day Camp) 

Form 5

Please fill out the form below.  

AUTHORIZATION TO DISPENSE MEDICATION

NSK shall not handout prescription or nonprescription medications to any child without specific written authorization from the child’s physician and/or parent/guardian. All medications shall be stored in accordance with the prescription instructions and kept in places that are inaccessible to children. Each dose of medication given to a child shall be documented showing the child’s name, name of medication, amount administered, date and time, and the name of the NSK staff member dispensing that medication. Parent/guardians will be contacted before any medication is dispensed to their child.

Date of Birth
Month
Day
Year

Permission is hereby granted to dispense medication(s) to the above mentioned minor child at the appropriate time.

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