Authorization To Administer Medication
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2Child Care Program Name & Address
AUTHORIZATION TO ADMINISTER MEDICATION
Complete entire form. Print clearly, using ink, not pencil.
Today’s Date:
Child’s name:
DOB:
Please administer medication as specified below:
Name of medication:
Expiration date:
Date medication begins:
Date medication ends:
Does medication need to be stored in the refrigerator?
Yes
No
What is the medication for?
Instructions for use of medication:
Dosage/amount:
How administered:
When is medication to be given? (Circle and specify):
•
At set times of day (specify time and AM/PM)
•
When symptoms occur (such as pain, asthma, etc. - describe clearly):
_________________________________________________________________
•
In an emergency (such as allergic reaction, anaphylaxis – describe clearly):
_________________________________________________________________
Special instructions (such as with/without food; foods to avoid, etc.)
_______________________________________________________________________
How soon should medicine take effect (relief of symptoms, etc.):
_______________________________________________________________________
Possible side effects (such as drowsiness):
_______________________________________________________________________
Possible complications and treatment:
_______________________________________________________________________
Attach additional instructions from doctor, if necessary.
Doctor’s name:
Phone: _____________
Address: __________________________________________________________________
Parent/guardian name (printed): ________________________________________________
Parent/guardian signature: ____________________________________________________
Relationship to child:
Date: _____________________
Parents must pick up any medicines at the end of each week. Medicine will not be given to
child or sibling to take home.
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Parent category: Business