Allergy & Medication Authorization
Youth Programs
Child's Name
Date of Birth
Age
Parent/Guardian Name
Emergency Contact Number
Allergy Information
List all known allergies
Describe typical reaction(s) and treatment
Medication(s) required for allergies (if any)
Medication Authorization
Medication Name
Dosage
Time(s) and Frequency
Reason for medication
Medication Storage Instructions
Is child permitted to self-administer?
Yes
No
Authorization
Physician Name (if applicable)
Physician Phone
Parent/Guardian Signature
Date