HomeMy WebLinkAboutAdministration of Medication Consent Form.pdf
CCFL CC 103b
Child Care Application Package - September 9, 2005
Administration of Medication Consent Form
CHILD’S NAME:
PHYSICIAN’S NAME: PHONE:
PHARMACY NAME: PHONE:
MEDICATION: PRESCRIPTION #:
DOSAGE OF MEDICATION: HAS THIS MEDICATION BEEN ADMINISTERED TO THIS CHILD PREVIOUSLY? YES NO
IF NO, HAS CHILD RECEIVED MEDICATION FOR 24 HRS PRIOR TO YES NO
RETURNING TO THE CHILD CARE PROGRAM?
TIMES TO BE GIVEN BY PARENT:
TIMES TO BE GIVEN BY CARE PROVIDER:
ANY POSSIBLE SIDE EFFECTS THAT YOU HAVE BEEN MADE AWARE OF BY THE PHYSICIAN OR PHARMACY?
I hereby give permission and authorize _____________________________________ to
administer the medication in the dosage as stated above. This dosage is consistent with the
recommendations of the Physician and/or drug manufacturer. I accept the responsibility of
supplying the current correct medication in its original container, and I agree to submit a new
consent form if there is any change in the medication to be administered.
Signature of Parent/Guardian
Date
Phone
Caregiver’s Administration Record:
DATE: TIME GIVEN: AMOUNT GIVEN: ADMINISTERED BY: