Authorization To Administer Medication Page 2
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2Child Care Program Name & Address
MEDICATION ADMINISTERED IN CHILDCARE
Daily Medication Form
To be completed each day medication is given.
Complete entire form. Print clearly, using ink, not pencil.
Date: __________________________
Child’s name:
DOB: _________________
Name of medication: ___________________________________________________________
Time medication last given at home:
AM PM (circle one)
Given by: _________________________
Time(s) medication given at child care program:
Given by: (print name and signature)
AM PM
Name (print): ________________________________________
Signature: __________________________________________
AM PM
Name (print): ________________________________________
Signature: __________________________________________
AM PM
Name (print): ________________________________________
Signature: __________________________________________
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Parent category: Business