REQUEST FOR ADMINISTRATION OF MEDICATION FOR CHILD CARE

Please correct the errors described below.

The following section must always be completed by the parent/guardian.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

The following section must be completed by a licensed physician, licensed dentist, advanced practice registered nurse or certified physician's assistant.

  1. The medication contains codeine or aspirin.
  2. A physician's instruction is needed for a nonprescription medication (e.g. child does not meet minimum age or weight requirements as listed on the label instruction).
  3. It is a sample medication without a prescription label.
  4. The nonprescription medication is to be given longer than three consecutive days within a fourteen day period.
  5. The topical product or lotion and the physician's instructions exceed the manufacturer's instructions or use.
(May not exceed twelve months from the date of this request for medication of food supplements).

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

The following section must be completed by the center, family child care provider or in-home aide for the child listed on page one of this form. All medication must be documented when administered.

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This form is valid for no longer than twelve months and must be kept on file at the center or home for at least one year following the last administration of the medication or product. One form must be used for each medication.

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