AUTHORIZATION FOR DISPENSING MEDICATION
Name of Child to Receive Medicine
Name of Medication
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
CAREGIVER’S RECORD OF ADMINISTERING MEDICATION
NAME OF MEDICATION
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 & Time