Authorization For The Administration Of Medication Form - Cheshire Community Ymca printable pdf download

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)

Authorization For The Administration Of Medication Form - Cheshire Community Ymca