MEDICATION AUTHORIZATION FORM
Prescription and non-prescription drugs, including vitamins and aspirin, will be given to a child ONLY
with the parent or guardian’s COMPLETED written consent.
Child’s Name _________________________________________ Date of Birth ___________________
Child’s Known Allergies: ______________________________________________________________
MCC has my permission to administer the following medication:
Medication Name and Prescription Number: _______________________________________________
Time(s) to be Administered: ____________________________________________________________
Special Instructions: ___________________________________________________________________
Adverse Reaction, if any: _______________________________________________________________
Non-prescription Drugs: This form will expire ten (10) business days from the effective date. If
medication is still required, a new form will have to be completed. This medication must be taken home
daily and brought back the next day if so required.
Date of Authorization: ______________________________________
Prescription or Long Term Over-the-counter Drugs: This form will expire one year from the
effective date. If medication is still required, a new form will have to be completed. A physician’s
Authorization Form is also required for Long Term medications. This medication can be kept on site.
Date of Authorization: _______________________________________
Signature of Parent and/or Guardian ______________________________________________________