Free template · Health and safety

Medication authorization form

Parent permission for staff to give a child medicine: the medicine, dose, times and dates, signed before the first dose. Use it with the medication log.

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What's in it

What the medication authorization covers

At the top: We can give your child medicine only with this signed form and the medicine in its original labeled container. Please fill out one form for each medicine and hand the medicine to a staff member. Don't leave it in your child's bag. If anything doesn't match this form or the label, we won't give the medicine, and we'll call you.

Child

Child's full name
Date of birth
Weight (if the dose depends on weight)
Allergies, including medicine allergies

Medicine

Check one.

Prescription
Non-prescription (over the counter)
Medicine name and strength
Reason for the medicine
Dose and how it's given (such as by mouth or inhaler)
Times to give it
For 'as needed' medicines: the signs that mean your child needs it, and how often it may be given
Start and end dates
Expiration date (we don't give expired medicine)
Prescriber's name and phone (for prescriptions)
How to store it (such as in the refrigerator)
Side effects to watch for
Last dose given at home (date and time)

Before the first dose

Check each one that's true.

My child has taken this medicine before without a problem
The medicine is in its original container, labeled with my child's name (for prescriptions, with the pharmacy label)
The dose on this form matches the label or the doctor's written instructions

Emergency medicines

For epinephrine auto-injectors, asthma inhalers and other emergency medicines, please attach your child's action plan from their health care provider.

Allergy or asthma action plan attached

Health care provider's instructions (if required)

[Our program or our state] requires written instructions from the child's health care provider for [prescription medicines, some non-prescription medicines and any dose that's different from the label].

Health care provider's printed name and phone
Health care provider signature and date

Parent or guardian permission

I give permission for trained program staff to give my child the medicine on this form, as described here and on the label. I'll tell the program in writing if anything changes, and I'll pick up any medicine that's left after the end date.

Parent or guardian's printed name
Parent or guardian signature
Date
Phone during the day

For program use

Received by (staff) and date
Medicine checked against the label and this form (initials)
Medication log started (date)
Medicine returned to the parent (date and amount left)

Free to use and change, but not legal or medical advice. Check your state's licensing rules and your insurer's requirements, and have a lawyer review any consent or waiver language.

Tips

How to use it well

Use one form for each medicine, and record every dose on the medication administration log. Keep the form and the log with the medicine, out of children's reach. Lock up other medicines if your state requires it, but keep epinephrine, inhalers and other emergency medicines unlocked, where staff can grab them in seconds.
Before every dose, check the right child, right medicine, right dose, right time and right way. If anything doesn't match the parent's form or the label, don't give the medicine. Call the parent and the director.
Ask your health consultant to review your medication policy. Caring for Our Children (CFOC), the national health and safety standards for early care and education, covers giving medicine in childcare in detail.
Check your state's licensing rules on who may give medicine, what training they need, whether a health care provider must sign for non-prescription medicines and how long a permission lasts. Find your state's rules at backpr.com/resources/states.

Rules on ratios, medication and reporting vary by state. See your state in our state-by-state rules for youth programs.

FAQ

Questions, answered

What's the difference between a medication authorization form and a medication log?

The authorization form is the parent's written permission for one medicine, with the dose, times and dates. The log is the staff record of every dose actually given. Most programs need both, so keep them together with the medicine.

Do we need a doctor's note to give children over-the-counter medicine?

It depends on your state. Some states require written instructions from a health care provider for non-prescription medicines, and staff shouldn't give a dose that's different from the label without them. Check your state's licensing rules.