Medication Form printable pdf download

Medication Form

Saskatchewan Learning

(As Required)

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.

Medication Authorization

* A separate form must be completed for each type of medication administered.

Child's Name: _______________________________________________________________________________________

Name of Medication: __________________________________________________________________________________

Dosage: ___________________________________________________________________________________________

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.

Date:

Signature of parent/guardian

Year

Month

Day

Medication Record

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.

TIMES ADMINISTERED

Date

Year/Month/Day

Time

Initials

Time

Initials

Time

Initials

Comments

(Termination record on reverse)

7794

Rev.07/07

Medication Form