Permission to Administer Medication in Child Care
(ONE FORM PER MEDICATION)
To be completed by the child’s health care provider with prescribing authority:
Child: ____________________________________________________ Birthdate: __________________
Medication: ______________________________________________________________________________
Dosage: __________________________________________________ Route: _____________________
Time of day medication is to be given: _______________________________________________________
Special Instructions: _______________________________________________________________________
Purpose of medication: ____________________________________________________________________
Possible side affects: ______________________________________________________________________
Start date: ____________________________________ End date: _________________________
______________________________________________ __________________ ____________________
Signature of Person with Prescriptive Authority Phone # Date
Print Name: ___________________________________
Too be completes by the parent or guardian:
I hereby give my permission for _________________________________________ to take the above
(child’s name)
medication, in child
care, as ordered by the health care provider. I understand that it is my
responsibility
to furnish this medication.
________________________________________________________
____________________
Signature of Parent or
Guardian
Date
Note: The medication
is to be brought to child care in the original container which clearly
states the child’s
name, the health care provider, the name of the medication, date, time and
dosage. This form must also be
filled out completely in order for the medication to be given. This is the
Division of Child Care Licensing
requirement.
Please ask the pharmacist for a separate medicine bottle to keep at child care.
Thank you!