Child Care Facility Authorization For Prescription And Non-Prescription Medication Form

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Child Care Facility
Authorization for Prescription and Non-Prescription Medication
No medication shall be given by child care personnel without the signed permission of the parent or
legal guardian. All medication must be in the original container with the child's name, name of the
physician, medication name, and medication directions written on the label.
Non-prescription medication brought in by the parent or legal guardian can only be dispensed if there is
written authorization from the parent or legal guardian to do so.
Medication which has expired or is no longer being administered shall be returned to the parent or legal
guardian.
Child’s Name: __________________________________ Age: _______________________________
Medication which has expired or is no longer being administered shall be returned to the parent or legal
1. Medication Name: ____________________________________________________________
guardian.
Amount to be Given: ______________________ Time to be Given: _____________________
Start Date: ______________________________ End Date: ___________________________
2. Medication Name: ____________________________________________________________
Amount to be Given: ______________________ Time to be Given: _____________________
Start Date: ______________________________ End Date: ___________________________
Record of Medication Given
1. Medication Name: ____________________________________________________________
Date and Time
Amount
Employee Signature
________________
_________________
__________________________
________________
_________________
__________________________
________________
_________________
__________________________
________________
_________________
__________________________
________________
_________________
__________________________
2. Medication Name: ____________________________________________________________
Date and Time
Amount
Employee Signature
________________
_________________
__________________________
________________
_________________
__________________________
________________
_________________
__________________________
________________
_________________
__________________________
________________
_________________
__________________________
This authorization form must be maintained and is only valid for the duration of the prescription.
I hereby give permission to dispense the medication(s) listed above in accordance with the written
directions on the prescription label or printed manufacturer’s label.
____________________________________________________
_________________________
Parent/Guardian Signature
Date
(Retain in child’s file for a minimum of four months)

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