Authorization for the Administration
of Medicine Form

Parents/Guardians requesting medication administration to their child by daycare staff shall provide the program with appropriate written authorization(s) and the medication before medications are dispensed. Medications must be in the original container and labeled with child's name, name of medication, directions for medication's administration) and date of the prescription. All unused medication will be destroyed if not picked up within one week following the termination of the authorized prescriber's order.
Authorized Prescriber's Order (Physician, Dentist, Physician Assistant, Nurse Practitioner)

I request that medication be administered to my child as described and directed above and attest that I have administered at least one dose of the medication to my child without adverse effects.

I request that medication be self administered to my child as directed above.

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