Authorization to give Medication-Leesburg Montessori

AUTHORIZATION TO GIVE MEDICATION

Prescribed drugs shall be given to a child only in accordance with a signed doctor’s order or authentic prescription label and with the parent’s and guardian’s written consent for each separate occurrence. We cannot administer medication in the ears or eyes. You are welcome to return to school to give this medication to your child.
CHILD’S NAME
DATE
Date Format: MM slash DD slash YYYY
NAME OF DAY CARE PROVIDER
CHECK THE BOX BESIDE THE STATEMENT:
- Montessori School of Leesburg has my permission to administer the following drug and medication
DRUG NAME AND/OR PRESCRIPTION NUMBER
DOSAGE TO BE GIVEN
TIMES TO BE GIVEN
SPECIAL INSTRUCTIONS (if any)
THIS AUTHORIZATION IS EFFECTIVE UNTIL
Date Format: MM slash DD slash YYYY
PARENT NAME
PARENT EMAIL
PARENT’S/GUARDIAN’S SIGNATURE
CHECK THE BOX BESIDE THE STATEMENT (DAY CARE PROVIDER ONLY):
- I agree to administer the drugs or medication specified above only as directed, to keep the medication out of reach of all children, and to return the unused portion or empty prescription packaging to the parent(s)/guardian(s) when it is no longer needed or at the time specified above:
DATE
Date Format: MM slash DD slash YYYY
SIGNATURE OF DAY CARE PROVIDER
This form is suggested by the Virginia Department of Welfare as a model for use by the Child Care center of Family Day Care Home. The information on this form is required by Minimum Standards.

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Montessori School of Leesburg & Purcellville