MEDICATION AUTHORIZATION FORM

AUTHORIZATION FOR DRUG/MEDICATION ADMINISTRATION
This form must be completed by the parent of a child who is requesting that a drug or medication be administered during hours that the child receives child care, in accordance with the child care centre's medication administration policy and procedures.
Child's Name*

First NameLast Name
Child's Date of Birth *

MonthDayYear
Date
Date Authorization Form Completed *

MonthDayYear
Date
Date Authorization Form Updated

MonthDayYear
Date
Name of Drug or Medication*
(as per the original container label)
Expiry Date of Medication

MonthDayYear
Date
Date of Purchase or Date Dispensed

MonthDayYear
Date
Authorization Start Date

MonthDayYear
Date
Authorization End Date or Ongoing

MonthDayYear
Date
Method of Medication Administration

Child care centre staff are to administer the drug or medication to my child.My child will self-administer the drug or medication (optional, for children who attend school only).
Authorization for Child to Carry Emergency Allergy Medication

I authorize my child to carry their own asthma medication.Not applicable (this authorization is not for asthma medication).
Medication Administration Schedule:

The drug or medical needs to be administered according to the following schedule:
Days of the week
Times of the day / Intervals
Amount/Dosage
Additional Information (where applicable)
AND/OR, where drugs are to be administered on an 'as needed' basis: The drug or medication needs to be administered when the following physical symptoms are observed:
Dosage
Parent/Guardian Authorization Statement:

I hereby authorize the person in charge of drugs or medications at Orange Seeds Montessori Centre to administer the above-named drug or medication to my child and handle the drug or medication in accordance with the procedures I have provided on this form.

I understand that expired drugs or medications will not be administered to my child at any time in accordance with the child care centre's medication administration policy.

I understand that staff at Orange Seeds Montessori Centre are not medically trained to administer drugs and medications.
Print name
Relationship to Child
Signature

Clear
Date signed

MonthDayYear
Date
Parent's Email:
example@example.com
Received by:
Print name
Role at Child Care Centre
Signature

Clear
Date signed

MonthDayYear
Date
Special Instructions:
- This form is required for over-the-counter and prescription medications. For non-prescription skin products, the Authorization to Administer Non-Prescription Skin Products form must be completed.
- A separate form should be completed for each drug or medication that a child requires.
- Children's personal health information should be kept confidential.
For Child Care Centre Use Only
Location medication will be stored
Should be Empty:

AUTHORIZATION FOR DRUG/MEDICATION ADMINISTRATION