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Child Care Medication Authorization Form

Child Care Medication Authorization form Name of Child : : Today s Date: Name of Medication : Reason for Medication : Dose: Time/Frequency: Route: Date to Start: Date to stop: Expiration: Additional Instructions/Comments: Known side effects: I authorize ( Child care center) personnel to administer the Medication named above to my Child in the manner as stated. I release any liability in relation to the administration of this Medication . I also acknowledge that I, the parent/guardian, have given the first dose of this Medication without any allergic or unexpected reactions.

ALWAYS review the written Parent/Guardian medication instructions and Health Care Provider's medical order (when necessary according to regulation) prior to EVERY administration. Instructions should be attached to this sheet.

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