Medication Authorization Form printable pdf download

MEDICATION

AUTHORIZATION FORM

TO BE COMPLETED BY PARENT

Child’s Name__________________________________________________________

Date of Birth_____/____/___

Program Name________________________________________________________

Today’s Date_____/____/___

********************************************************************************

To administer a prescription medication:

The medication must be in it’s original container, with a legible label from the pharmacy

The child’s name, date, name of medicine, dosage, and time, number of days medication is to be given, and

expiration date of medication, doctor’s/nurse practitioners name, pharmacy name and telephone number

• Samples must be accompanied by a doctor’s written prescription

• Medications are to be given only to the child indicated on the label (twins and siblings can not share.)

• A separate authorization is required for each medication and each episode of illness

• Label constitutes the physicians/nurse practitioner’s order

• Parent/Guardian is to give as many doses as possible at home.

Medication:_______________________________________________________________________

Reason for giving__________________________________________________________________

Start date_____/____/___ End date____/____/____

Dosage:_______________ Times to be given at child care:________AM_______PM

Last dosage was given at_________AM/PM On date____/____/____

Route: by mouth, skin (location)________, eye (R/L)

Possible side effects:______________________________________________________________

Special handling/storage Instructions_______________________________________

Refrigeration Y/N

Parent/Guardian Signature (required)_______________________________________________

Physician/Nurse Practitioners Signature

____________________________________________________

****************************************************************************************

Non-Prescription Medication:

•

Parent is required to bring these medications from home.

• Medication must be in an original container, with child’s name on the container.

Medication:__________________________________Health Care Provider_________________

For children under 2, list the name of the health care provider who recommended this

medication."

Reason for giving:________________________________________________________________

Start date_____/____/___ End date____/____/____

Dosage:_______________ Times to be given at child care:________AM_______PM

Last dosage was given at_________AM/PM on date____/____/____

Route: by mouth, skin (location)________, eye (R/L)

Note: Epipens and Allergies: We realize the importance of educating staff in handling life-threatening allergies.

In today's climate, it's something that is quite common. Staff training regarding life threatening allergies ensures a

proactive approach to safety. Our staff are CPR and First Aid trained so they will respond appropriately should there

be an anaphylactic and/or allergic reaction. [Please bring two (2) epipens to camp. Your child should keep an

epipen on them at all times and we will keep the other in our first aid kit, which is always located close

to our staff. Please be sure to label all of your child's epipens with their first and last name.

Unused medication: Returned to Parent Y/N or, discarded appropriately (circle one)

By: ________________________________________________ Date _____/_______/_______

*Keep in the child’s file when medication is finished.

Medication Authorization Form

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