Depot Daycare

Medical Release Form

Name of Child: Age: 

Name of Medication:

Condition Being Treated: 

Date(s) Medication is to be Given:


Time(s) Medication is to be Given:  

Method of Administration (for example, orally, topically, nasally, etc.): 

Possible Side Effects or Interactions with Other Drugs: 


I hereby give my permission for the provider to administer this medication according to the instructions above. I agree that the provider will not be held liable for any illness or injury resulting from the administration of this medication, and will not be held responsible for the reimbursement of any medical expenses resulting from such action. 

Leave this empty:

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Signature Certificate
Document name: Medical Release Form
lock iconUnique Document ID: e90cc82efe2c6fa33aed5b163cd3ba504f9b66e6
Timestamp Audit
March 30, 2018 12:26 pm MDTMedical Release Form Uploaded by Ty Singleton - IP