Victory Hill Dorm Medication and Supplements (CF4080)

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Victory Hill Dorm Medication and Supplements

The personal information collected on this form will be used for the purpose of service plan and evaluation and will be treated confidentially in compliance with the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information please contact the Director, Provincial Deaf and Hard of Hearing Services at (604) 660-1800 (voice), (604) 660-1807 (TTY), 4334 Victory St, Burnaby BC, V5J 1R2.

Child/Youth

Date of Birth (MM/DD/YYYY)

Medication or Dietary Supplements

Under the Community Care and Assisted Living Act the Victory Hill Dorm must secure the written approval of the Family
Doctor and/or parents to administer Over the Counter (OTC) Medications and/or Dietary Supplements. Please review the
list below of OTC medications provided by VHD. Please check the box which medications VHD staff may administer to
the child/youth when symptoms are present and in accordance with the manufacturer’s directions. Please provide any
special instructions.
Pain Relievers
Cough and Colds
Allergies
Laxatives
 
First Aid/Other

Signature

Who is completing this form:
Date Signed (MM/DD/YYYY)
Signature
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Submission

Click the PDF button to generate a printable version and submit the complete form.
Mail to:
Victory Hill Dorm, c/o Patrick Tarchuk
4334 Victory Street
Burnaby BC V5J1R2
 
Please mark the envelope CONFIDENTIAL.
Fax To:
604-660-1859
 
VHD will return a copy of this form to the parent/guardian for their verification and records.
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