ESDAA Tournament Medication Permission

i request and give permission for my child, _________________________________ to receive the following medication during the ESDAA Basketball Tournament held at (School), in (City/State) on (Date). (Please submit a separate sheet for each medication.)

Name of Medication: _________________________________

Dosage; _________________________________

Time(s) to be taken: _________________________________

How it is administered: _________________________________

I understand that I must send the medication in the original labeled container. All of the above information is on the label on the container prepared by the pharmacist as prescribed by:

Name of Physician: _________________________________

Telephone Number: _________________________________

Physicians' Signature: _________________________________ Date: __________

Parent/Guardians' Signature: ____________________________ Date: __________

Please describe any allergies or health problems that your child has.

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