Authorization For Dispensing Medications To Children And Youth Short-Term Medications (Prescription And Non-Prescription)
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2Kansas Department of Health and Environment
CCL.026
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
Short-Term Medications (Prescription and Non-Prescription)
Prescription medication 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/youth 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.
Medication #1
Medication #2
__________________________________________
__________________________________________
First and Last Name of Child/Youth
Date of Birth
First and Last Name of Child/Youth
Date of Birth
__________________________________________
__________________________________________
Name of Medication
Name of Medication
__________________________________________
__________________________________________
Reason for Medication
Reason for Medication
__________________________________________
__________________________________________
Dose
Time to be Given
Stop Date
Dose
Time to be Given
Stop Date
__________________________________________
__________________________________________
Name of Licensed Physician/PA/APRN prescribing
Name of Licensed Physician/PA/APRN prescribing
the medication
the medication
(_________)________________________________
(_________)________________________________
Phone Number of Physician, PA, or APRN
Phone Number of Physician, PA or APRN
I allow the above medication to be given to my child/youth
I allow the above medication to be given to my child/youth
by the designated person.
by the designated person.
__________________________________________
__________________________________________
Parent’s Signature
Parent’s Signature
Date
Date
THIS FORM IS TO BE USED TO DOCUMENT ADMINISTRATION OF ONLY THE MEDICATION(S) IDENTIFIED ABOVE.
Designated Person to note any comments or remarks about the child’s/youth’s appearance on the back of this form.
Date
Time
Name of Medication
*Initials
Date
Time
Name of Medication
*Initials
mm/dd/yy
mm/dd/yy
*Each designated person administering medication is to sign on the back side of this form and identify initials used above.
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