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MARYLAND STATE DEPARTMENT OF EDUCATION

OFFICE OF CHILD CARE

Seizure Medication Administration Authorization Form

Name of Child Care Facility ___________________________________________________________________

This form authorizes emergency seizure care for _________________________________________________ ❒ M ❒ F

(Child’s Name)

(Date of Birth)

while attending the above named child care facility during child care hours. This form must be completed by the

child’s physician and signed by both physician and parent.

Treating Physician

______________________________ Phone#____________________ # After Hours_____________

Significant Medical History

: _________________________________________________________________________

Seizure Care Information

Seizure Type

Length

Frequency

Description

Seizure Triggers or Warning Signs: ____________________________________________________________________

Seizure Emergency Protocol (Check all that apply and clarify below)

❒ Call 911 for transport to ____________________________________________❒ Notify parent or emergency contact

❒ Notify treating physician _____________________________❒ Other_______________________________________

❒ Administer emergency medications as indicated below:

Emergency

Dosage Time

Route/method

Side Effects

Special Instructions

Medication

Does child need to leave the classroom after a seizure? ❒ Yes ❒ No If YES, describe process for returning the child to

the classroom. ______________________________________________________________________________________

Special Considerations and Precautions (regarding activities, sports, trips, etc.) __________________________________

________________________________________________________________________________________________________________________

Physician Signature: ____________________________________________________ Date: _______________________

Parent Information & Authorization: Medications must be in the original container and labeled with the child’s name,

name of medication, directions for medication’s administration, and date of the prescription. I request that medication

be administered to my child as described and directed above and attest that I have administered at least one dose of the

medication to my child without adverse effects. I agree to review special instruction and demonstrate the medication

administration procedure to the child care provider. I understand the risk and authorize for administration of

emergency seizure medication to my child.

Parent/Guardian Signature: ______________________________________________ Date: ______________________

OCC 1216A (8/20/15)

Seizure Medication Administration Authorization Form - Maryland State Department Of Education