SNACK & Friends, Inc. - Medication Authorization Form

Medication Authorization Form

Complete this form once for each medication that your child will be taking.

Parent/Guardian

You will receive a confirmation by email.

First name *

Last name *

Email *

Child (participant)

First name *

Last name *

Date of birth *

Name of medication *

Name of medication

What is the unit dose? *

For example, how many mg per tablet?

What is the unit dose?

Medication Format *

Liquid Spray Capsule Tablet Other x Clear

If other, please specify

Photo of medication

What is the dosage? *

What is the dosage?

What time is it administered? *

What time is it administered?

How is it administered? (Crushed, With Juice, mix in with apple sauce, etc..) *

How is it administered? (Crushed, With Juice, mix in with apple sauce, etc..)

By submitting this form, I authorize my child's community habilitation worker and/or SNACK staff to administer the medication as described above.

I read and accept *

Electronic signature

Please sign your name inside the box

Type your name

Signature style

Electronic signature Signature pad

A required field has not been filled.

Please accept all conditions.

Connect to fill this form

Please type in your email or mobile number. We will send you a connection code.

Email or mobile

Connection code

Waitlist

Leave us your coordinates. We will contact you when a spot frees up.

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Membership

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