Medication Log Form
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2MEDICATION LOG FORM
55 Pa. Code §3270.133; §3280.133; §3290.133
All medication, whether prescription or non-prescription, must be accompanied by a Medication Log signed by the
parent/guardian of the child BEFORE any medication will be administration by our facility. Protocol for children requiring
medication during child care hours is as follows:
o For Prescription Medications, the child’s health care provider must complete and sign in section two below.
o Child must have previously received a medication before facility personnel will administer during child care, excluding Epi-Pens.
o Medication only accepted in original labeled container or box with child’s name. Please submit all Action Plans for emergency-use.
PLEASE ONLY LIST ONE MEDICATION PER FORM
⎕ Prescription – FORM SIGNED BY HEALTH CARE PROVIDER
⎕ Non-Prescription – FORM SIGNED BY PARENT
CHILD NAME ________________________________________________ AGE _________ PROGRAM _______________________
TYPE
NAME
DOSAGE
TIME(S)
EXPIRATION DATE
⎕ Epi-Pen:
_______________________
_______________
_________________
______/______________
⎕ Inhaler:
_______________________
_______________
_________________
______/______________
⎕ Oral:
_______________________
_______________
_________________
______/______________
⎕ Topical:
_______________________
_______________
_________________
______/______________
⎕ Sunscreen:
_______________________
_______________
_________________
______/______________
REASON FOR MEDICATION _________________________________________________________________________________
SPECIAL CONSIDERATIONS __________________________________________________________________________________
EFFECTIVE DATES (Please include all dates when child is enrolled in child care) __________________________________________
TO BE COMPLETED BY PRESCRIBING HEALTH CARE PROVIDER FOR PRESCRIPTION MEDICATIONS
It is my understanding that the employees of a child care facility charged with the administration of this treatment/procedure during child
care hours rely on directions contained in this document. I further certify that I am the health care provider who prescribed the
treatment and that the child named above is under my supervision as a patient.
SIGNATURE OF HEALTH CARE PROVIDER ______________________________________________________________________
OFFICE ADDRESS ___________________________________________________________________________________________
CONTACT PHONE ________________________________________________
DATE ______________________________
TO BE COMPLETED BY CHILD’S PARENT/GUARDIAN
As the parent/guardian of the above named child, I hereby request that the treatment described above be administered to my child and
release Camp Curiosity, Curiosity Shoppe, and Toddler Center Inc. and its employees from liability for any damages my child may
suffer as a result of this request.
SIGNATURE OF PARENT/GUARDIAN ___________________________________________________________________________
PRINTED NAME OF PARENT/GUARDIAN _______________________________________________________________________
CONTACT PHONE ________________________________________________
DATE ______________________________
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