Before you give any medicine at daycare, you need the parent's written permission with the exact medicine, dose and times, and a record of every dose you give. This form puts both on one page. The parent fills in the top half and signs it; you fill in the log each time you give a dose.
Keep the medicine in its original container with the child's name on it, and check your state's child care licensing rules, which may ask for more, such as a doctor's signature for prescription medicine. This is a blank form, not medical or legal advice.
Medication Permission and Log
| Child's name | Date of birth |
| Medicine name | Prescription or over the counter |
| Reason for the medicine | Dose (amount) |
| Times to give it | How to give it (by mouth, cream or inhaler) |
| First day | Last day |
| How to store it | Possible side effects to watch for |
| Doctor or prescriber | Doctor's phone |
I give permission for the daycare to give my child the medicine above, as written.
Parent or guardian signature ______________________________ Date ____________
| Date | Time | Dose given | Given by (initials) | Notes |
|---|---|---|---|---|