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

Last Name

First Name

Date of Birth (MM/DD/YYYY)

Personal Health Number

Family Doctor

Band Status Number

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

Special Instructions

Special Instructions

Special Instructions

Cough and Colds

Special Instructions

Special Instructions

Allergies

Special Instructions

Special Instructions

Laxatives

Special Instructions

Special Instructions

Special Instructions

First Aid/Other

Special Instructions

Special Instructions

Special Instructions

Special Instructions

Special Instructions

Special Instructions

Name of Other Medication/Supplement not Listed Above

Special Instructions

Signature

Who is completing this form:

Name

Date Signed (MM/DD/YYYY)

Signature

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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