Free Day Care Medication Record Form Template
Day Care Medication Record Form
Please complete this form to ensure the safe administration of medication to your child during daycare hours.
Child’s Name
Date of Birth
Parent/Guardian Name
Phone number
Medication Information
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Medication Name |
Dosage |
Frequency |
Reason for Administration |
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Administration Record
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Date |
Time |
Staff Name |
Notes |
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Parent/Guardian Authorization
I hereby grant permission to the daycare staff to provide and administer the medication specified above to my child.
Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit the medication record form.
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