Parent Permission To Give Medications Form
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1
2Child Name: ______________________________
Monthly Medicine Record: Month ____________ Year _______
Child Known Allergies:
Parent Permission to give medicine: I give my permission for the child care business to give the following medicine(s) to my child.
Date:
Parent Signature Giving
Name of medicine on the
Medicine dose
Time of day
Route of
Possible side
Required storage:
Permission:
label:
on the label:
medicine is to be
medicine as on
effects:
Refrigerate
given at child
the label:
1
care:
Refrigeration
not required
2
Reason medicine needed:
Special instructions for giving medicine:
Medicine is doctor approved and
doctor authorization form on file at
child care
Beginning date for medicine: __________
Ending date for medicine: ____________
Date:
Parent Signature Giving
Name of medicine on the
Medicine dose
Time of day
Route of
Possible side
Required storage:
Permission:
label:
on the label:
medicine is to be
medicine as on
effects:
Refrigerate
given at child
the label:
care:
Refrigeration
not required
Reason medicine needed:
Special instructions for giving medicine:
Medicine is doctor approved and
doctor authorization form on file at
child care
Beginning date for medicine: __________
Ending date for medicine: ____________
Date:
Parent Signature Giving
Name of medicine on the
Medicine dose
Time of day
Route of
Possible side
Required storage:
Permission:
label:
on the label:
medicine is to be
medicine as on
effects:
Refrigerate
given at child
the label:
care:
Refrigeration
not required
Reason medicine needed:
Special instructions for giving medicine:
Medicine is doctor approved and
doctor authorization form on file at
child care
Beginning date for medicine: __________
Ending date for medicine: ____________
Parent permission to contact pharmacy and physician: I give my permission for the child care business to contact my child’s
pharmacy and physician should questions arise or a situation occur that involves my child and the medication.
Parent Name (print): _______________________________ Parent Signature: _______________________________ Date: _______
1
The time of day for the medicine needs to be consistent between home, child care and other programs where the child is located like school. Ask
the parent when the medicine is given at home so medicine doses may be evenly spaced for maximum benefit.
2
The medicine may need to be given before meals, after meals, with food, with a specific liquid (water or milk). All instructions should be written on
the medicine label or instructions. When in doubt, call the pharmacy where prescription medicine was dispensed.
January 2007
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