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To be completed by the Parent/Guardian:

Child's Name_____________________________________________________________

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

Name of Medication________________________________________________________

Dosage__________________________________________________________________

Over the Counter/Prescription                     Prescription Expiration_________________

Does Medication require refrigeration:  yes/ no

Medical Reason for Medication to be Given:____________________________________

Doctor's Name_______________________ Next Doctor's Visit_____________________

Any special instructions or side effects to watch for during administering:____________

_________________________________________________________________________

_________________________________________________________________________

Was any medication given at home prior to coming to child care? yes/ no

Parent/Guardian Authorization______________________________ Date_____________

TO BE COMPLETED BY THE PROVIDER:

Name of staff receiving Medication from Parent:__________________________________


Date GivenTime Given
Amount GivenGiven By        Side Effects/Reaction