In order for your child to be administered over the counter medication the following requirements set by the New York State Department of Social Services must be met:
*Medication must be in original container with all the information required by current regulations.
*Parent / Guardian must provide us with written instruction on space provided below.
*Over the counter medication may be administered on a non-routine basis with written instruction by the paent, if these do not conflict with the diections on the label of the medication container.
*Oral instructions by parents are acepted only if the symptoms develop while the child is in our care. Documentation of this approval must be made on this form by the provider. The __________________ Day Care, _____________ and staff do not assume any reposibilty of an allergic reaction or any other complication that your child may experience as a result of us following through with your demands. Please initial if you have read this and completely understand and accept all of these terms.
__________
Parent Initial
Date:____________
I_________________________________, the parent / guardian of ____________________________demand that my child be
administered the following medication___________________________________________________with the following dosage
every__________hours.
Medication is to be administered at the following times:
______:______a.m. p.m. ______:______a.m. p.m. ______:______a.m. p.m.
Other information or special instructions that should be followed:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If your child allergic to anything please list:
____________________________________________________________________________________________________
______________________________________
Parent / Guardian Signature Date
Oral Instructions: Staff this form must be filled out before administering any medication. This form and request must be witnessed by another staff member.
Child's Name:______________________________________Medication Name:______________________________________
Dosage:___________ First Dosage Time:______:______a.m. p.m. Second Dosage:______:_____a.m. p.m.
Name of Parent Requesting Medicationfor the child:_____________________________________________________________
Provider Signature:____________________________ Date:__________________
Provider Witness:_____________________________Date:__________________
Provider Note:_________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________.
