• Capacidad Individual Health Care Plan Form

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  • Date of birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Please fill out a Medication Consent Form for each medication the program may need to administer.

  • Medication that will be administered at the program must be provided by a parent/guardian in the original container(s) bearing the pharmacy label with the following information: the date of filling the pharmacy name and address the filling pharmacist's initials the serial number of the prescription the name of the patient the name of the prescribing practitioner the name of the prescribed medication directions for use and cautionary statements contained in such prescription or required by law if tablets or capsules, the number in the container

  • The date of filling
     / /
    2 digit month, 2 digit day, 4 digit year

  • All over-the-counter medications must be kept in the original containers containing the original label, which shall include the directions for use

    For Older Children ONLY (9+ years of age)
    In accordance with 606 CMR 7.11(3b-c) and with written parental consent and authorization of a licensed health care practitioner, this Individual Health Care Plan permits older school age children to carry their own inhaler and/or epinephrine auto-injector and use them as needed without the direct supervision of an educator.

    The educator is aware of the contents and requirements of the child's Individual Health Care Plan specifying how the inhaler or epinephrine auto-injector will be kept secure from access by other children in the program. Whenever an Individual Health Care Plan provides for a child to carry his or her own medication, the licensee must maintain on-site a back-up supply of the medication for use as needed.

  • Date of birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Commonwealth of Massachusetts Department of Early Education and Care

    MEDICATION CONSENT FORM 606 CMR 7.11(2)(b)

  • Please select one of the following
  • Date(s) medication to be given
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • I, , (parent or guardian) gives permission to authorize educator(s) to administer medication to my child as indicated above.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • For topical, non-prescription NOT applied to open wound / broken skin (parent signature only)

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  • Should be Empty: