Medication consent form and record sheet - Caring for Kids
Medication consent form and record sheet Program name / logo
Name of child: _______________________________________________________________________________ Date: ___________________________________________
I: To be completed by child’s parent or guardian
I, ______________________________________________________ [parent or guardian’s name], give permission for _____________________________________________________ [child’s name] to be given the following medication by child care staff according to instructions stated below. Parent/guardian’s signature: _____________________________________________________________________ Name of medication: ___________________________________________________________________________ ____________________________________________________________________________________________ Amount(s) to be given: _________________________________________________________________________ ____________________________________________________________________________________________ Dates(s) to be given [at child care]: _______________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Time(s) to be given: ___________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Name, address and phone number for child care centre or home setting
© Canadian Paediatric Society, 2008. Reprinted from Well Beings: A Guide to Health in Child Care (3rd edition). May be reproduced for educational purposes, and for use in child care settings.
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Special instructions: ___________________________________________________________________________ ____________________________________________________________________________________________ Storage: _____________________________________________________________________________________ ____________________________________________________________________________________________ Start date: _______________________________________ End date: ___________________________________ My child received ______ [number] doses at home. Are there any possible side effects from the medication? Please specify: ___________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Stop medication if the following reaction(s) is observed: _______________________________________________ ____________________________________________________________________________________________
II: To be completed by child care practitioner when the medication is given
Date
Time(s)
Amount
Given by (initials)
Comments: __________________________________________________________________________________ ____________________________________________________________________________________________
Name, address and phone number for child care centre or home setting
2 of 2
© Canadian Paediatric Society, 2008. Reprinted from Well Beings: A Guide to Health in Child Care (3rd edition). May be reproduced for educational purposes, and for use in child care settings.
Name of child: _______________________________________________________________________________ Date: ___________________________________________
I: To be completed by child’s parent or guardian
I, ______________________________________________________ [parent or guardian’s name], give permission for _____________________________________________________ [child’s name] to be given the following medication by child care staff according to instructions stated below. Parent/guardian’s signature: _____________________________________________________________________ Name of medication: ___________________________________________________________________________ ____________________________________________________________________________________________ Amount(s) to be given: _________________________________________________________________________ ____________________________________________________________________________________________ Dates(s) to be given [at child care]: _______________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Time(s) to be given: ___________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Name, address and phone number for child care centre or home setting
© Canadian Paediatric Society, 2008. Reprinted from Well Beings: A Guide to Health in Child Care (3rd edition). May be reproduced for educational purposes, and for use in child care settings.
1 of 2
Special instructions: ___________________________________________________________________________ ____________________________________________________________________________________________ Storage: _____________________________________________________________________________________ ____________________________________________________________________________________________ Start date: _______________________________________ End date: ___________________________________ My child received ______ [number] doses at home. Are there any possible side effects from the medication? Please specify: ___________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Stop medication if the following reaction(s) is observed: _______________________________________________ ____________________________________________________________________________________________
II: To be completed by child care practitioner when the medication is given
Date
Time(s)
Amount
Given by (initials)
Comments: __________________________________________________________________________________ ____________________________________________________________________________________________
Name, address and phone number for child care centre or home setting
2 of 2
© Canadian Paediatric Society, 2008. Reprinted from Well Beings: A Guide to Health in Child Care (3rd edition). May be reproduced for educational purposes, and for use in child care settings.
