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Kansas Department of Health and Environment

CCL.027

Rev. 5/2017

Bureau of Family Health

Child Care Licensing Program

1000 SW Jackson, Suite 200

Topeka, KS 66612-1274

Phone: 785-296-1270 Fax: 785-559-4244

Website:

Authorization for Dispensing Medications to Children and Youth

Long-Term Medications (Prescription and Non-Prescription)

Prescription medications must be in their original containers labeled with the child’s/youth’s first and last name; the name of

the licensed physician, physician assistant (PA), or advanced practice registered nurse (APRN) who ordered the medication; the

date the prescription was filled; the expiration date of the medication; and specific, legible instructions for administration and

storage of the medication. Administer the medication only to the child designated on the prescription label in accordance with

the instructions on the label. Non-prescription medications can be given with written permission and direction from the parent

or legal guardian. Administer nonprescription medication from the original container labeled with the first and last name of the

child/youth and according to the instructions on the label.

______________________________________________________________________________________________________

First and Last Name of Child/Youth

Date of Birth

______________________________________________________________________________________________________

Name of Medication (only one medication per authorization)

Prescription OR Non Prescription

_______________________________________________________________________________________________________

Reason for Medication

_______________________________________________________________________________________________________

Dose

Time to be Given

Start Date

Stop Date**

_______________________________________________________________________________________________________

Name of Licensed Physician, PA or APRN prescribing the medication

Phone # of Physician, PA or APRN

I allow the above medication to be given to my child/youth by the designated person.

_______________________________________________________________________________________________________

Parent’s Signature

Date Signed

**Stop date not to exceed one year from the start date. A new authorization is to be completed any time the medication, dosage, times to be given, or instructions

from the parent or health care provider change from the information included on this form. Additional copies of this form may be attached to this page if more

space is needed to record the administration of the medication for up to one year if there are no changes in instructions. Above information must be completed

on each page but the parent’s signature is required only once per year.

THIS FORM IS TO BE USED TO DOCUMENT ADMINISTRATION OF ONLY THE MEDICATION IDENTIFIED ABOVE. Designated Person to

note any comments or remarks about the child’s/youth’s appearance and/or condition on the back of the form.

Date

Time

*Initials

Date

Time

*Initials

Date

Time

*Initials