MEDICATION FORM

Separate form required for each medication

To be completed by the Parent:

Child’s Name____________________________________________________________________________

Dates Authorized to Give Medication_________________________________________(not to exceed 1 week)

Name of Medication_______________________________________________________________________

Dosage_________________________________                   Time to be given___________________________

Method to give Medication/Special Instructions:_________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

___________Does Medication require refrigeration: yes / no

Was any medication given at home prior to coming to child care?________________ Time:_________________

Parent/Guardian Authorization_______________________________________ Date:___________________

To be completed by the Provider:

Name of Staff Receiving Medication from Parent:_________________________________________________

Verification:

______Medication in original container      ______Medication not out of date     ______Labeled with child’s name

Date Given	Time Given	Amount Given	Given By	Side Effects/Reaction

 

Parent received information on administration of medication and unused medication returned to the parent:

Parent Signature:___________________________________________     Date:_______________________

(Note: must be a designated person to receive medication and a back up person if that staff member is out)