Simon Says Simon Says Simon Says
OVER THE COUNTER MEDICAL CONSENT FORM
 
I __________________________________ authorize “Simon Says” to administer the

Parent’s Name
 
following Over-The-Counter medications to my child _____________________________ .

Child’s Name                 

 
 
 
Name of Medication
Dosage
Special Instructions
       
1.
 ____________________ ____________________ ____________________
     
     
2.
 ____________________ ____________________ ____________________
     
     
3.
 ____________________ ____________________ ____________________
     
       
4.
 ____________________ ____________________ ____________________
       
       
5.
 ____________________ ____________________ ____________________

 

I authorize "Simon Says" to apply ___________________________________
                                                                       Name of Sunscreen/Bug spray

to my child_________________________________.

_________________________________

Parent Signature / Date

_________________________________
Physician Signature / Date