Medication Form

This form must be completed fully in order for childcare providers and staff to administer the required medication. A new medication form must be completed at the beginning of each 12-month period, for each medication, and each time there is a change in dosage or time of administration of medication.

• Prescription medication must be in a container labeled by the pharmacist or prescriber.
• Non-prescription medication must be in the original container with the label intact.
• Parent/Guardian must bring the medication to the facility.
• Must pick up the medication at the end of authorized period. otherwise it will be discarded

PRESCRIBER'S AUTHOTIZATION

PARENT/GUARDIAN AUTHORIZATION

I/We request authorized child care provider/staff to administer the medicaion as prescribed by the above prescriber. I attest that i have administered at least one dose of the medication to my hild without adverse effects. I/We certify that I/we have legal authority, understand the risk and consent to medical treatment for the child name above, including the administration of medication. I agree to review special instruction and demonstrate medication administration procedure to the child care provider.

SELF CARRY/SELF ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL

(Only school-aged children maybe authorized to self carry/self administer medication)
Self carry/self administration of emergency medication noted above maybe authorized by the prescriber.

FACILITY RECEIPT AND RENEW