AUTHORIZATION FOR DISPENSING MEDICATION

Name of Child to Receive Medicine

 

 

Name of Medication

 

Prescribing Physician

 

 

Prescription No.

 

Expiration Date

Dosage

 

 

When to Give

 

Continue Medication Until (date)

 

NOTE: Medication must be in its original container and labeled with your child’s name and the date medication is left at the facility.  Medication can only be administered in amounts according to the label directions.

 

 

 

 

Signature-Parent or Guardian

 

Date

 

 

CAREGIVER’S RECORD OF ADMINISTERING MEDICATION

CHILD’S

NAME

NAME OF MEDICATION

DATE GIVEN

TIME

GIVEN

AMOUNT

GIVEN

FULL NAME OF CAREGIVER OR EMPLOYEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disposition of Left-over Medication                                                                

 Returned to Child’s Parent/Guardian               Thrown Away                         Date:

I hereby request an employee to administer the medication named below to my child.  I understand that all medications must be in the original container, labeled with the child’s name and with directions to administer the medication.  Prescribed medication must also include the date and name of physician.  By signing below I release the child-care center and its employees from all liability for reactions which my child may suffer from this medication.

                                                     

Date

Child’s Name

 

Name of

Medication

Dosage

Time to

be

given

Parent’s

Signature

Dosage Given

Date & Time

Given

Employee’s

Full Name