Run Childcare Medication Authorization and Administration Record — Free

Child and Parent/Guardian Information

Child's full name (required)

Child's date of birth (required)

Parent/guardian full name (required)

Parent/guardian phone number (required)

Parent/guardian email

Relationship to child (required)

Medication Authorization

Medication type (required)

Medication name (required)

Reason medication is being given (required)

Dosage amount (required)

Enter the exact amount to administer, such as 5 mL, 1 tablet, or 2 puffs.

Dosage unit (required)

Route of administration (required)

When should the medication be given? (required)

Describe the timing or schedule, such as after lunch, every 6 hours, or as needed.

Authorization start date (required)

Authorization end date

Does this medication require refrigeration?

Yes No N/A

Are there special instructions or warnings?

Yes No N/A

Special instructions or warnings

I authorize childcare staff to administer this medication as written above (required)

Yes No N/A

Consent and disclosure acknowledgment (required)

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.

Yes No N/A

Medication Label and Supply Details

Prescription number or pharmacy reference

Prescribing provider name

Medication expiration date (required)

Medication is in the original labeled container (required)

Storage location (required)

Administration Log

Medication administration entries (required)

Dose status (required)

Reason medication was not given

Child response or reaction after administration

Staff Verification and Parent Follow-Up

Staff member full name (required)

Staff role (required)

Parent/guardian notified (required)

Notification method

Follow-up notes

Staff signature (required)

Get your results

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Run: Childcare Medication Authorization and Administration Record

Child and Parent/Guardian Information

Medication Authorization

Medication Label and Supply Details

Administration Log

Staff Verification and Parent Follow-Up

Get your results