CHILD CARE REGULATION MEDICATION AUTHORIZATION

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES

SECTION FOR CHILD CARE REGULATION

MEDICATION AUTHORIZATION
MEDICATION REQUIREMENT

PRESCRIPTION MEDICATION SHALL BE IN THE ORIGINAL CONTAINER AND LABELED WITH THE CHILD’S NAME, INSTRUCTIONS, INCLUDING TIMES AND AMOUNTS FOR DOSAGES, AND THE PHYSICIAN’S NAME. ALL NON-PRESCRIPTION MEDICATION SHALL BE IN THE ORIGINAL CONTAINER AND LABELED BY THE PARENT(S) WITH THE CHILD’S NAME AND INSTRUCTIONS FOR ADMINISTRATION, INCLUDING TIMES AND AMOUNTS FOR DOSAGES. A SEPARATE FORM IS NEEDED FOR EACH MEDICATION. THIS FORM IS VALID ONLY FOR THE DATES INDICATED BELOW.
I AUTHORIZE CHILD CARE PERSONNEL TO ADMINISTER THE FOLLOWING MEDICATION TO MY CHILD:
(PROPER NAME OF MEDICATION)*
CHILD’S FULL NAME*
DATE MEDICATION TAKEN FROM*

MonthDayYear
Date
UNTIL*

MonthDayYear
Date
DOSAGE*
TIME(S) OF DAY*
POSSIBLE SIDE EFFECTS
SIGNATURE OF PARENT(S) OR GUARDIAN
Signature

Clear
Signature DATE*

MonthDayYear
Date
FORM TO BE RETAINED IN CHILD’S RECORD
Should be Empty: