Medication Authorization Form

Child's Full Name *

First

Middle

Last

Medication *

Name of medication

Medication must be in the original container labeled with child's full name.

Child's weight in pounds (lbs)

Layout

Dose to be given *

Provider must administer the medication in amounts according to the label directions or as amended by a physician.

Measurement *

Motrin

Tylenol

Time to be given

Time to be given 2

Time to be given 3

Good for six months

If a child has a recurring medical problem, such as headaches, asthma attacks, or allergic reactions, the parent or the child's health-care professional may sign a medication authorization form allowing the provider to administer the medication for up to a six-month period. If this is applicable to your child please check the box.

Symptoms to watch for *

Additional Symptoms

Competency Statement *

I have determined Heidi Pearson competent to give or apply medication to my child(ren). I understand that Almost Mom Child Care has a responsibility to assess the ability of staff to give or apply medication safely and may give or apply medication to my child(ren).

Today's Date *

Email *

Parent Signature *