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Medication Administration Form
Student First Name
Student Last Name
Parent/ Guardian Name
Allergies
The following medications may be administered to my student by a Student Ministry staff, Host Home or Small Group Leader:
Medications
All the medications listed here
Tylenol
Anti-Diarrhea
Ibuprofen
Benadryl (other allergy meds)
Dramamine
Antacid Tablets
Hydrocortizone Cream
Please list any over the counter or prescription medicines that need to be taken during this weekend
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