Form 07lc066e (Occ-66) - Medication Permission
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1
2*07LC066E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES
Medication Permission
I hereby authorize
to administer to
Name of facility
the medication listed below, which has
Name of child
been supplied by me and which is clearly labeled:
Medication:
Instructions:
Reason for medication:
Refrigerate:
Yes
No
I understand this form is supplied by the Oklahoma Department of Human Services
(OKDHS) for the convenience of the child care facility and me and that supplying the
form in no way imposes any responsibility or obligation upon OKDHS.
Signature of parent or guardian
Date
Amount
Date
Time dispensed
Initials
dispensed
Issued 9-1-2002
07LC066E (OCC-66)
Page 1 of 2
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