Authorization for Administering Medications

DHR-CDC-1949

AUTHORIZATION FOR ADMINISTERING MEDICATION/MEDICAL PROCEDURES

Dear Parent/guardian,

Your written permission is required to administer medication or medical procedures to your child. Any prescription drug or over-the-counter drug sent to the child care facility (home or center) must be in its original container and must be clearly labeled with your child's name, the name of the drug, and directions for administering the drug. A new authorization form is needed each week. If it is absolutely necessary for your child to be given medication while at the child care facility, please complete the following information.

Child's Name

Prescription Number

Name of Medication

Amount of medication to be given at each dosage

Instructions (how to give or apply, such as given by mouth, apply to skin, inhale, drops in eyes, etc.)

Time and date of last dosage given at home

Date

Time(s) of dosage(s) to be given at the child care facility

Please give my child the above-named medication at the time(s) and in the amount(s) indicated.

Signature of Parent/Guardian

Date