Parent/guardian Authorization For The Administration Of Non-Prescription Topical Medications By Child Care Personnel printable pdf download

Parent/guardian Authorization For The Administration Of Non-Prescription Topical Medications By Child Care Personnel

Parent/Guardian Authorization for the Administration of

Non-Prescription Topical Medications by Child Care Personnel

To Child Care Personnel:

I hereby request that the following non-prescription topical medications be administered to my child by a

child care staff member of the _________________________________.

(Name of child day care program)

I understand that I must supply the child care program with the non-prescription topical medication in the

original container labeled with the child’s name, name of the medication, and the directions of the

medication administration.

This authorization is limited to the following topical medications:

1. Diaper changing or other ointments free of antibiotic, antifungal or steroidal medications

2. Medicated powders

3. Teething, gum, or lip medications

Name of Child:___________________________________Date of Birth:_____________

Address:________________________________________________________________

Name of Medication:______________________________________________________

Schedule of Administration:_________________________________________________

Site of Administration:_____________________________________________________

Reason medication is being administered:______________________________________

Medication shall be administered from:_________________ to:____________________

Name of Parent/Guardian________________________________ Date:______________

I have administered at least one dose of the above medication to my child without adverse side effects.

Signature:_______________________________ Relationship to child:_______________

Address:_________________________________ Telephone:______________________

Staff to complete:

Parent authorization form and medication received by:___________________________

(Signature of staff)

Medication Started:_____________________________________

(date and time)

Medication Ended:_____________________________________

(date and time)

Parent permission and medication administration record shall become part of the child’s health record when the medication has ended.

S:\Division\Licensure\Group&Ctr\FieldForms\Authorization-AdminMeds-NonTopical&MAR.doc 4/2/09

Parent/guardian Authorization For The Administration Of Non-Prescription Topical Medications By Child Care Personnel