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Medical Information /

Administration Form 

By completing this document

I,

(Parent/Guardian), give permission for Wymbin to administer medication outlined below to my child (stated in Minor's Information Section) in the event of an emergency. 

December 21, 2024


First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Allergy/Illness *

Name/Type of Medication (described on container) *

Medication Prescribed by *

Expiry Date on Medication *

Full Directions and Use including: - Dosage and method - Timing - Special Precautions - Staff or self-administration? - Procedures to take in emergency *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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