Child Care Medication Authorization Form

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Child Care Medication Authorization Form
Name of Child:
D.O.B.:
Today’s Date:
Name of Medication:
Reason for Medication:
Dose:
Time/Frequency:
Route:
Oral
Topical
Inhaled
Injection
Other
Date to Start:
Date to stop:
Expiration:
Additional Instructions/Comments:
Known side effects:
FOR PRESCRIPTION MEDICATION
Prescribing Health Care Provider:____________________________________________
Phone Number: _________________________________________________________
FOR CONTROLLED SUBSTANCES
Amount of Medication Received:____________________________________________
Staff Member Signature:__________________________________________________
Staff Member Signature:__________________________________________________
I authorize (child care center)
personnel to administer the medication
named above to my child in the manner as stated. I release any liability in relation to the administration
of this medication. I also acknowledge that I, the parent/guardian, have given the first dose of this
medication without any allergic or unexpected reactions.
Parent/guardian printed name:
Date Signed:
Parent/guardian signature:
RETURN OR DISPOSAL OF MEDICATION
Return Date: ____________________ Parent Signature:_________________________
Disposal Date:____________________ Staff Signature:___________________________
Witness to Disposal: _________________________________

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