# Medication authorization form

Source: https://backpr.com/resources/templates/medication-authorization-form. Last updated: 2026-10-22.

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.

Free download: PDF https://backpr.com/media/templates/backpr-medication-authorization-form.pdf · Word https://backpr.com/media/templates/backpr-medication-authorization-form.docx

> 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): ______

### How to use it
- 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.

**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.

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.