Medication Administration Authorization
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2MARYLAND STATE DEPARTMENT OF EDUCATION
OFFICE OF CHILD CARE
MEDICATION ADMINISTRATION AUTHORIZATION FORM
Child Care Program:
This form must be completed fully in order for child care providers and staff to administer the
required medication. A new medication administration form must be completed at the beginning
of each 12 month period, for each medication, and each time there is a change in dosage or time
of administration of a medication.
• Prescription medication must be in a container labeled by the pharmacist or prescriber.
• Non-prescription medication must be in the original container with the label intact.
• Parent/Guardian must bring the medication to the facility.
Child’s Picture (Optional)
otherwise it will be discarded.
• Must pick up the medication at the end of authorized period,
PRESCRIBER’S AUTHORIZATION
Child’s Name:
Date of Birth:
Condition for which medication is being administered:
Medication Name:
Dose:
Route:
Time/frequency of administration:
If PRN, frequency:
(PRN=as needed)
If PRN, for what symptoms:
Possible side effects &special Instructions:
Medication shall be administered from:
_to_
Month I Day / Year
Month I Day I Year (not to exceed 1 year)
Known Food or Drug: Allergies? Yes No If Yes, please explain___________________________________________
Prescriber’s Name/Title
:
(Type or print)
Telephone:
FAX:
Address: _______________________________________________________
Prescriber’s Signature:
____Date:
(Original signature or signature stamp ONLY)
This space may be used for the Prescriber’s Address Stamp
PARENT/GUARDIAN AUTHORIZATION
I/We request authorized child care provider/staff to administer the medication as prescribed by the above prescriber. I attest that I have
administered at least one dose of the medication to my child without adverse effects. I/We certify that I/we have legal authority, understand the
risk and consent to medical treatment for the child named above, including the administration of medication. I agree to review special instruction
and demonstrate medication administration procedure to the child care provider.
Parent/Guardian Signature:
Date:
Home Phone #:
Cell Phone #:
Work Phone #:
SELF CARRY/SELF ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL
(Only school-aged children may be authorized to self carry/self administer medication.)
Self carry/self administration of emergency medication noted above may be authorized by the prescriber.
Prescriber’s authorization: ______________________________________________________________________________
Signature
Date
Parental approval: ____________________________________________________________________________________
Signature
Date
FACILITY RECEIPT AND REVIEW
Medication was received from:
Date:
□
□
Special Heath Care Plan Received:
YES
NO
Medication was received by:
Signature of Person Receiving Medication and Reviewing the Form
Date
OCC 1216 (Revised 08/20/15) – All previous editions are obsolete.)
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Parent category: Medical