Authorization to Administer Medication
Must be in the original container with the child's name, dosage, and directions for administration.
All over the counter and short-term medication will be sent home daily.
Medication will not be given if missing any information.
Staff will call the child's parent prior to administering an "as needed" medication.
Child's Name
*
First Name
Last Name
Birth Date
*
/
Month
/
Day
Year
Authorization Start Date
*
/
Month
/
Day
Year
Date
Authorization End Date
*
/
Month
/
Day
Year
1 day max for over the counter meds. 1 year max for long term meds such as epi-pens
Reason for Medication
*
Example: ear infection, pink eye, diaper rash, etc
Name of Medication
*
As listed on the package
Type of Medication
*
Please Select
Prescription
Over the Counter
Diaper Cream
Other
Other Type
*
How to be administered
*
Please Select
Orally
Topically
By Device*
Other
*If by a device, detailed instructions and demonstration of use must be provided
Other Administration Type
*
Medication Expiration Date
*
/
Month
/
Day
Year
Must match medication label
Dosage Amount
*
If different than label, provide a doctor's note
Date Last Given at Home
/
Month
/
Day
Year
Time Last Given at Home
Minutes
AM
PM
AM/PM Option
Times to be administered at Learning Ladder
*
If "as needed", describe symptoms in next box
If as needed describe symptoms
Does the over the counter (OTC) medication label indicate a physician should be consulted?
*
Please Select
Yes
No
N/A
If Yes, I have consulted with my child's physician, and I am authorizing a dosage consistent with the physician's recommendation. Initial here.
*
Additional Information or Special Instructions
Parent Name
*
First Name
Last Name
Email
*
You will receive a confirmation email with a copy of the completed form
Date
*
/
Month
/
Day
Year
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