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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. 


May 18, 2025


First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
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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