G.USA WG: Authorization for the Administration of Medication

Gymnastics USA

AUTHORIZATION FOR ADMINISTRATION OF MEDICATION
Prescription Medications:
Must have a current pharmacist’s label that includes:
01) Child’s full name
02) Dosage
03) Current date
04) Times to be administered
05) The name and telephone number of the physician.

Non-prescription Medication:
Can be administered according to the manufacturer’s instructions with written authorization from the parent/guardian via this form.

Topical Ointments:
Can be administered according to the manufacturer’s instructions with written authorization from the parent/guardian via this form.
Child's Name:*

First NameLast Name
Medication Type:*
Medication:*
Administration Method:*
Medication Storage:*
Dosage:*
Times/Frequency to Administer:*
I have read the Policy on Administering Medications and Ointments and I hereby authorize G.USA agents to administer the here stated medication to my child. I further agree to indemnify and hold harmless G.USA, and their agents and servants, against all claims as a result of any and all acts performed under this authority and according to the instructions below.*
Your Full Name:*

First NameLast Name
E-mail:*
Phone Number:*

Area CodePhone Number
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