Medication Authorization Form - CHC Version - Child Care Medication Admin Approval

Sep 18, 2026

Medication Authorization Form for child care programs to delegate staff to administer prescribed medications after required approvals. The form collects child identity, medication, dosage, and dates, and outlines procedures for licensed group child care settings, including provider/parent signatures, medication labeling, safe storage, staff recording, and emergency contact. It also specifies that certain conditions require a detailed health care plan beyond this authorization and includes a health care provider section for dosage, route, timing, instructions, and side effects.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Medication Authorization Form

Policy Overview and Procedures

Authorization for Medication Administration

Parent/Guardian Information

Health Care Provider Section

MEDICATION AUTHORIZATION FORM | Child’s Name: | Date of Birth: | | --- | --- | | Medication: | Dose: | The program will administer medication to children for whom a plan has been made and approved by the Director. Medication in the facility can present a safety hazard, parents should check with the child’s health care provider to see if a dose schedule can be arranged to be administered at home. Parent/guardian may come to administer medication to their own child during the day. Procedures for Medication in Licensed Child Care of Group Care Settings: 1. All medications or treatments require a health care provider and parent/guardian to complete and sign this form. 2. The program’s Child Care Health Consultant will review this Medication Authorization Form and sign. 3. Over-the-counter medication must be the original container and labeled with the child’s name. Prescription medication must have a pharmacy label that corresponds with the written order from the health care provider. 4. All medications will be stored out of the reach of children and returned to the parents once prescription is completed or medication has expired. Parents are responsible for providing measuring devices (for example, a syringe) for accurate medication administration. 5. All medication administrations will be recorded by the staff administering the medication. 6. Children with conditions such as asthma, severe allergies, diabetes, oxygen, feeding tubes and seizure disorder require a detailed health care plan in addition to, or in lieu of, this Medication Authorization Form. Please see staff for a copy of a healthcare plan. Medications: ● Are administered in accordance with the pharmacy/medication label directions and as prescribed by the written instructions from the child’s health care provider. ● The instructions from the child’s parent/guardian shall not conflict with the label directions or as prescribed by the child’s health care provider. ● Require a written prescription or completed Medication Authorization Form from the child’s health care provider. AUTHORIZATION FOR MEDICATION ADMINISTRATION Parent statement: I have read the above policy and hereby authorize delegated staff to administer the prescribed medication to my child as designated on this form. By checking this box, I give permission for my child’s health care provider to share information about the administration of this medication with the program’s nurse or school staff delegated to administer medication. Parent/Guardian name Telephone Parent/Guardian signature Date In case of emergency, please contact Telephone This portion completed by child’s health care provider | Medication: | Dosage: | Route: | | --- | --- | --- | | Time of Administration: | Start date: | End date: | | Special Instructions: | | | | Purpose of Medication: | | | | Side effects to be reported: | | | Signature of Health Care Provider Date: Printed Name of Health Care Provider Phone/Fax: / Child Care Health Consultant signature Date:

FAQs

Who must complete and sign the medication authorization form?

A health care provider and the parent/guardian must complete and sign the form. The Child Care Health Consultant also reviews and signs it.

What labeling requirements apply to over-the-counter and prescription medications?

Over-the-counter medication must be in the original container labeled with the child’s name. Prescription medication must have a pharmacy label that matches the written order from the health care provider.

How are medications stored and when are they returned to parents?

Medications are stored out of children’s reach and returned to parents once the prescription is completed or the medication has expired.

Sep 18, 2026

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