Authorization For The Administration Of Medication Form - Cheshire Community Ymca


Authorization for the Administration of Medication by Child Care Personnel
In Connecticut, licensed Child Day Care Centers, Group Day Care Homes and Family Day Care Homes administering
medications to children shall comply with all requirements regarding the Administration of Medications described in the
State Statutes and Regulations. Parents/guardians requesting medication administration to their child by daycare staff shall
provide the program with appropriate written authorization(s) and the medication before any medications are dispensed.
Medications must be in the original container and labeled with child’s name, name of medication, directions for
medication’s administration, and date of the prescription. All unused medication will be destroyed if not picked up within
one week following the termination of the authorized prescriber’s order.
Authorized Prescriber’s Order
(Physician, Dentist, Physician Assistant, Advanced Practice Registered Nurse):
Name of Child __________________________ Date of Birth ___/____/____ Today’s Date ____/____/____
Condition for which drug is being administered during childcare hours __________________________________
Medication Name _____________________________________________ Controlled Drug? YES NO
Dosage ___________________ Method _________________ Time of Administration____________________
Specific Instructions for Medication Administration _______________________________________________
Medication Administration Start Date _____/_____/_____ Stop Date _____/_____/_____
Relevant Side Effects of Medication __________________________________________________________
Plan of Management for Side Effects _________________________________________________________
Known Food or Drug: Allergies?
YES NO Reactions to? YES NO Interactions with? YES NO
If “yes” to any of the above, please explain _____________________________________________________
Prescriber’s Name ____________________________________ Phone Number (_____)_________________
Prescriber’s Address ________________________________________________ Town _________________
Signature ___________________________________________________
Parent/Guardian Authorization:
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.
Name of Day Care Program _____________________________________ today’s Date _____/_____/_____
Child’s Name __________________________ Address __________________________Town_____________
Name of Parent/Guardian Authorizing Administration of Medication __________________________________
Relationship to Child: Mother Father Guardian/Other explain: _____________________________
Address _______________________________ Town ______________Phone Number (_____) ___________
Signature of Parent/Guardian Authorizing Administration of Medication _______________________________
Name of Childcare Personnel Receiving Written Authorization and Medication _____________________
Title/Position ____________________ Signature (in ink) ________________________________________
S:\Division\Licensure\Grp&Ctr\Field Forms\G_C_AdminMeds.doc 3/31/04 (Website)


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