I/We  _____________________________ hereby authorize Pamela, and/or agent to use the following products on my/our child ____________________________ according to the manufacturer or physician’s written instructions or to administer the following medications to my/our child. I/We __________________________ understand that when medication is given according to instructions, I/we ________________________ will not hold Pamela Ball and/or agent liable for any reactions or complications that may follow as a result of my child receiving medication.

Today’s Date __________________________

Child’s Name _________________________________ Birthdate ____________________________

Diaper Ointment                                    YES – NO                       Brand _____________________

First Aid Ointment                                 YES – NO                       Brand _____________________

Insect Spray                                          YES – NO                       Brand _____________________

Sunscreen                                             YES – NO                       Brand _____________________ 

Tylenol                                                  YES – NO                       Dosage_____________________

Motrin                                                   YES – NO                       Dosage_____________________

Other ________________                       YES – NO                       Brand _____________________

Other ________________                       YES – NO                       Dosage ____________________

Child’s Weight ______________________

Child’s Age _________________

Physician’s Signature ________________________________ Date _______________________

Physician’s Address ________________________________

                              ________________________________ 

Physician’s Phone Number ____________________________

Parent/Guardian’s Signature __________________________ Date _______________________

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