THE COMMONWEALTH OF MASSACHUSETTS
THE COMMONWEALTH OF MASSACHUSETTS
Department of Early Education and Care
Parental Permission for Medication/Medication Administration
Use this form to obtain written permission for any prescription or non-prescription medication the parent/guardian may ask you to administer. Use the log below to document the medication you have given.
I, _____________________________ give my permission to STEPPING STONES
(Parent’s/Guardian’s name)
LEARNING CENTER to administer the following medication to
___________________________ beginning on ___________ and ending on ______.
(Child's Name) (Date) (Date)
Name of medication:_____________________________________________________
_________________________________________________________________________
(dosage, # of times per day and # of days for that week the medication is to be administered)
_____My child has taken this medication before.
_____ My child had not taken this medication before I gave it to my child on_____ at _____.
date time
_________________________________ _______________________
Parent’s/Guardian’s Signature Date
****************************************************************************************************
Medication Administration
|DATE |TIME |DOSAGE |METHOD OFADMIN |GIVEN BY |
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| | | | | |
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Name of Child:_____________________________________________________________
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