Allergy Medication Administration Consent Form
Child's Full Name
Date of Birth
Parent/Guardian Information
Parent/Guardian Name
Contact Number
Email Address
Allergy Details
Describe Allergy
Allergen(s) (specify food, medication, etc.)
Typical Reaction/Symptoms
Medication Information
Medication Name
Dosage
Route of Administration (e.g., oral, injectable)
Frequency / Timing
Special Instructions
Authorization
I authorize the designated personnel to administer the above medication to my child as specified. I agree to notify the organization of any changes in the medication or administration.
Parent/Guardian Signature
Date
Staff Signature
Date