Medication Form

Medication Authorization

"*" indicates required fields

This form must be signed prior to any medications being dispensed. Note: Any prescription medication prescribed as “PRN” REQUIRE a written statement from the licensed health care professional prescribing the medication allowing Next Generation Child Care and Preschool to dispense the medication. This also include medication that must be administered by a route other than oral, topical, inhalant or instillation, or when label states “contact physician for dose”.

Today’s Date:*

Child’s Full Name:*

Date of Birth:*

Name of Medication:*

Dose:*

Time to dispense medication:*

Additional Instructions:*

Start Date for Medication:*

End Date for Medication:*

By signing this form, I hereby give permission and deem Next Generation Child Care and Preschool to administer medicine as prescribed above. I acknowledge that I have administered at least one dose of this medication to my child without adverse effects.

Parent/Guardian Signature:*

Phone Number:*