Form Lic 9221 - Parent Consent For Administration Of Medications And Medication Chart
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PARENT CONSENT FOR ADMINISTRATION OF MEDICATIONS AND MEDICATION CHART
NOTE: Regulation Section 101221 requires the following information be on file.
CHILD CARE CENTER NAME:
LICENSE NUMBER:
DATE:
Bethel Lutheran School
PARENT’S INSTRUCTIONS:
1.
All prescription and nonprescription medications shall be maintained with the child’s name and shall be dated.
2.
Prescription and nonprescription medications must be stored in the original bottle with unaltered label. Medications
requiring refrigeration must be properly stored.
3.
Prescription and nonprescription medication shall be administered in accordance with the label directions.
4.
Written consent must be provided from the parent, permitting child care facility personnel to administer medications
to the child. Instructions shall not conflict with the prescription label or product label directions.
CHILD’S NAME
DATE OF BIRTH
MEDICATION NAME
DOSAGE
I authorize child care personnel to assist in the administration of medications described above to the child named
above for the following medical condition/s:
From ____________________ to __________________ at ___________________ daily while in attendance.
BEGINNING DATE
ENDING DATE
TIME OF DAY
PARENT’S SIGNATURE:
DATE:
MEDICATION CHART
Staff Documentation of Medicine Administration
DATE
TIME GIVEN
STAFF SIGNATURE
DATE
TIME GIVEN
STAFF SIGNATURE
DATE
TIME GIVEN
STAFF SIGNATURE
DATE
TIME GIVEN
STAFF SIGNATURE
DATE
TIME GIVEN
STAFF SIGNATURE
Upon completion, return medicine to parent or destroy, and place form in child’s record.
DATE
STAFF
Depending on duration, additional pages may be attached for documentation of medicine administration.
This form must be completed for any medication, prescription and/or over the counter, including diaper rash cream.
LIC 9221 (8/08)
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