Medicine Form

MEDICATION PERMISSION AND INSTRUCTIONS

CHILD CARE HOMES AND CENTERS

Department of Licensing and Regulatory Affairs
Child Care Licensing Bureau

If you are giving or applying any medication to a child in care, the following must be completed by the parent for each medication. An interruption in medication will require a new permission form.

To Be Completed By Parent

I give my permission for(Required)

(Caregiver, Facility)

to give or apply the medication(Required)

(Specify, prescribed medication/over the counter product)

to my child(Required)

(Child's Name)

as follows:

DIRECTIONS:

Date to Begin Giving Medication(Required)

Date to Stop Medication(Required)

Time Medication is to be Given(Required)

Amount (dosage) of Medication Each Time Given(Required)

Storage of Medication(Required)

Other Directions, If Any

Signature of Parent(Required)

Date(Required)

TO BE COMPLETED BY THE CAREGIVER GIVING MEDICATION:

DATE	TIME	AMOUNT GIVEN	CAREGIVER'S NAME	CAREGIVER'S SIGNATURE

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