Free Daycare Form

Medication Authorization Form

Simple medication authorization and administration record.

Childcare Medication Documentation

Child Information

Child's Full NameDate of BirthClassroom / Group

Medication NameReason

DoseRouteTime / FrequencyStorage

Start DateEnd Date

Administration InstructionsSide Effects / What Staff Should Watch For

Physician / PrescriberPrescriber PhoneParent / GuardianParent Phone

I authorize childcare staff to administer the medication listed above according to the instructions provided.

Parent / Guardian Signature

Date