Hand in Hand
3860 Middle Road
Bettendorf, Iowa 52722
email us: info@handinhandqc.org

Phone: (563) 332-8010   Fax: (563) 332-7396
Medication Profile
Participant's Name:*
Parent or Guardian name:*
Parent or Guradian email address:*
Primary Physician:*     Phone #:*
Pharmacy:*     Phone #:*
Allergies:*

Parents/Guardians: Please list all medications your child is currently taking, regardless of if he/she will be taking them during Hand-in-Hand programs.

If your child does not take any medications, please write NONE in the first field below.

Medication Name/Dose:

Time(s) Given:     Possible side effects:
Medication Name/Dose:

Time(s) Given:     Possible side effects:
Medication Name/Dose:

Time(s) Given:     Possible side effects:
Medication Name/Dose:

Time(s) Given:     Possible side effects:
Medication Name/Dose:

Time(s) Given:     Possible side effects:
Medication Name/Dose:

Time(s) Given:     Possible side effects:
      * - Mandatory Fields.

Hand-in-Hand is a non-profit organization that assists families with special needs. We exist to expand the capabilities, confidence and quality of life for children and young adults of all abilities by providing programs designed to encourage fun, learning and social interaction in a positive environment.