Non-Prescription Medication Form
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1Non-Prescription Medication Form
Child's Name _______________________________ Date _________________
I authorize my child care provider, _____________________________________________ to
use the following products on my child according to the manufacturer or a physician's
written instructions. I will not hold the above named provider liable when the products
are used according to these terms.
Parents are responsible for providing the following items. All items must be in the original
container and clearly labeled with the child's name.
Please circle yes or no and add a brand name where necessary.
Baby Wipes:
Yes - No Brand _______________________ Comments _________________________________
Diaper Ointment
Yes - No Brand _______________________ Comments _________________________________
Baby Lotion/Powder
Yes - No Brand _______________________ Comments _________________________________
Sunscreen
Yes - No Brand _______________________ Comments _________________________________
Insect Repellent
Yes - No Brand _______________________ Comments _________________________________
First Aid Ointments
Yes - No Brand _______________________ Comments _________________________________
Parent Signature: __________________________________________________
Parent Signature: __________________________________________________
Provider Signature: _________________________________________________
This form will be reviewed annually.
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