I hereby give authority to the Supervisor/Assistant Supervisor at Pukerua Bay After School Care Group to administer medication provided by me as described below:

*Name of Parent

*Name of Child

*Name of Medication

*Medication Dosage

*Purpose or Symptoms

*Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2011