Family Child Care Sample Forms Packet Page 7
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12Parental Permission for Medication/Medication Administration
Use this form to obtain written permission for any prescription or non-prescription medication the
parent/guardian may ask you to administer. Use the log below to document the medication you
have given.
I, __________________________________________ give my permission to ______________________
(Parent’s/Guardian’s name)
_______________________________________ to administer the following medication to
(Educator/s)
___________________________ beginning on _________________ and ending on ______________.
(Child's Name)
(Date)
(Date)
__________________________________________________________________________
Name of medication
__________________________________________________________________________
(dosage, # of times per day and # of days for that week the medication is to be administered)
_____My child has taken this medication before.
_____My child had not taken this medication before I gave it to my child on ___________ at _________.
date
time
_________________________________
________________________________
Parent’s/Guardian’s Signature
Date
_________________________________________________________________________
Medication Administration
Name of Child:_____________________________________________________________________
Date
Time
Medication Dosage
Method of
Given By
Administration
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Page 7 of 12
FCCSampleFormPacket20100203
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