Child Care Regulation 26(1) requires every licensee who agrees to administer medication to a child to: (a) obtain prior written
authorization to administer the medication from the child's parent; and (b) ensure written records of each dose of medication
administered to a child are maintained.
* A separate form must be completed for each type of medication administered.
Child's Name: _______________________________________________________________________________________
Name of Medication: __________________________________________________________________________________
Times of day to be administered:
Child care centre or child care home provider name: _________________________________________________
I hereby authorize staff of the above named child care centre or child care home to administer the above named
medication in the dosage and the times of day indicated to the above named child.
Note: Personal health information may be disclosed by the facility to the Department of Learning
in the course of reviewing the facility's record keeping obligations.
Signature of parent/guardian
To use this medication record, list the dates down the left hand column and indicate the times of day that the medication
was administered. The person who administers the child's medication must place his/her initials in the appropriate box.
(Termination record on reverse)