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Non-Prescription Permission Form

Parent/Guardian Authorization for the Administration of
Non-Prescription Topical Medications by Child Care Personnel

 

ALL INFORMATION IS REQUIRED. FAILURE TO FILL OUT ALL FIELDS WILL RESULT IN HAVING TO START OVER.

To Child Care Personnel:

I hereby request that the following non-prescription topical medications be administered to my child by a child care staff member of the .

I understand that I must supply the child care program with the non-prescription topical medication in the original container labeled with the child�s name, name of the medication, and the directions of the medication administration.

This authorization is limited to the following topical medications:

1. Diaper changing or other ointments free of antibiotic, antifungal or steroidal medications
2. Medicated powders
3. Teething, gum, or lip medications
4. Insect repellants
5. Sunscreen free of PABA or its derivatives

Name of Child: Date of Birth:

Address:

City: State: Zip:

Name of Medication:

Schedule of Administration:

Site of Administration:

Reason medication is being administered:

Medication shall be administered from: to:

Name of Parent/Guardian: Date:

Parent/Guardian Email:

I have administered at least one dose of the above me dication to my child without adverse side effects.

Signature:  Relationship to child:

Address: Telephone:

Medication Administration Record (MAR)

Name of Child: Date of Birth:

Pharmacy Name: Prescription Number:

Medication Order:

Date Time Dosage Remarks Was This Medication Self Administered? Signature of Person Observing or Administering Medication
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Authorization form is complete Medication is appropriately labeled

Medication is in original container Date on label is current

Person Accepting Medication (print name): Date:

 

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