Childcare Medication Authorization and Administration Record

Parent/provider authorization form and administration log for prescription or over-the-counter medication given to a child in care.

Child and Parent/Guardian Information

• Child's full name
• Child's date of birth
• Parent/guardian full name
• Parent/guardian phone number
• Parent/guardian email
• Relationship to child

Medication Authorization

• Medication type
• Medication name
• Reason medication is being given
• Dosage amount
  Enter the exact amount to administer, such as 5 mL, 1 tablet, or 2 puffs.
• Dosage unit
• Route of administration
• When should the medication be given?
  Describe the timing or schedule, such as after lunch, every 6 hours, or as needed.
• Authorization start date
• Authorization end date
• Does this medication require refrigeration?
• Are there special instructions or warnings?
• Special instructions or warnings
• I authorize childcare staff to administer this medication as written above
• Consent and disclosure acknowledgment
  I understand that only the medication and instructions provided here will be followed, that staff may contact me or emergency services if needed, and that this record will be kept as part of the child's care file.

Medication Label and Supply Details

• Prescription number or pharmacy reference
• Prescribing provider name
• Medication expiration date
• Medication is in the original labeled container
• Storage location

Administration Log

• Medication administration entries
• Dose status
• Reason medication was not given
• Child response or reaction after administration

Staff Verification and Parent Follow-Up

• Staff member full name
• Staff role
• Parent/guardian notified
• Notification method
• Follow-up notes
• Staff signature