JC Sunshine Childcare Medical Consent Form
Complete this form to give consent for health-related items and medications for your child. Ensure all details are accurate and upload necessary documents.
Specific Consent Choices
Parents must list the exact product name and provide it in the original labeled container.
JC Sunshine Childcare does not administer oral over-the-counter medication. Parent/guardian consent on this form is for approved topical products, emergency medication with required documentation, or medication with required written orders and program approval.
JC Sunshine Childcare may use generic daycare-provided products in the categories marked Yes by the parent/guardian. Parents may request the product brand/name before use. If a child has allergies, sensitivities, or needs a specific product, the parent/guardian must notify the program in writing and provide required documentation.
Insect/bug spray
*
Yes
No
Insect/bug spray - Instructions
Complete if Yes
Lotion/moisturizer
*
Yes
No
Lotion/moisturizer - Instructions
Complete if Yes
Lip balm
*
Yes
No
Lip balm - Instructions
Complete if Yes
Topical ointment
*
Yes
No
Topical ointment - Instructions
Complete if Yes
First aid ointment
*
Yes
No
First aid ointment - Instructions
Complete if Yes
I understand that only the items I marked Yes may be used or administered. Items marked No may not be used unless I submit a new written consent.
*
I understand that only the items I marked Yes may be used or administered. Items marked No may not be used unless I submit a new written consent.
Type of Consent
*
Medication
Emergency Medication
Diaper Cream
Sunscreen
Topical Product
Other
Child Information
Child’s Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Classroom / Group
Please Select
Infant
Toddler
Preschool
Pre-K
School Age
Other
Consent Type
If Other, please specify
Select all that apply.
Medication/Product Information
Medication/Product Name
*
Purpose / Condition Treated
*
Dosage / Instructions
*
Route of Administration
*
Please Select
Oral
Topical
Inhaled
Eye
Ear
Nasal
Other
Frequency / Times
*
Start Date
*
 -
Month
 -
Day
Year
Date
Medication Container Confirmation and Change Acknowledgment
*
Medication will be provided in the original labeled container
Any changes to medication, dosage, or instructions require new consent
Prescriber/Health Care Provider Information
Prescriber/Health Care Provider Name
*
First Name
Middle Name
Last Name
Office/Clinic Name
*
Office Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Order Details
Parent/Guardian Consent and Acknowledgment
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Grandparent
Foster Parent
Other
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Acknowledgments
*
This form does not replace any official OCFS form, medical statement, prescriber order, MAT requirement, or documentation requested by JC Sunshine Childcare or NYS OCFS
Consent is valid only for the stated product and time period
The product must be provided in the original container
Any changes require a new consent form
I understand and agree to any other required OCFS-style acknowledgments
Digital Signature and Date
*
Submit
Submit
Should be Empty: