The medical Authorization form may not be submitted via email.
Please complete the fields in the below form, print, sign and deliver to the front desk.
The completed, signed form may be faxed to: 478-745-6030
Sandy’s Sandbox Child Care & Learning Center, Inc.
MEDICATION AUTHORIZATION FORM
Child’s Name:
Dates to be given:
Name of medication: Dosage: RX#:
Medication should given at home whenever possible. Except for first aid, staff members will not dispense prescription or non-prescription medication without a specific written authorization from the child’s physician and the parent. Diaper ointments, baby orajel, sunscreen and bug spray do not require a physicians authorization, however, a parent authorization will still apply. Medication will only be dispensed out of its original container, which must be labeled with the child’s name and dosage. Medical authorizations must be updated every Monday. When medication is brought to the center, it is to be given to the staff person in charge for proper storage. Appropriately licensed persons shall only administer non-emergency injections unless the parent and the physician of the child sign a written authorization for the child to self-administer the injection. Medication times are 11:00 am and 3:00 pm. Medication, which is to no longer be dispensed, will be returned to the child’s parent.
Please indicate the time(s) you want medicine given: 11:00 A.M. 3:00 P.M.
Signature Parent / Guardian: ______________________________
Date: _____________
DATE: ___________ TIME: _______ AMOUNT: __________ INITIALS: ________
REACTION: ______________________________________________________
If noticeable adverse reaction to medication, what action was taken?
Describe:____________________________________________________
____________________________________________________
SSCC&LC, Inc. Developed 3-06
