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Microsoft word - medication authorization and notice

If your child requires an over the counter medication, such as Motrin or Tylenol, we are required by the state of Massachusetts to have proper authorization on file for each medication. These medications are generally left at the center to be used in the case of your child having a fever, teething, or other ailments directed by you and your child’s physician. Over the counter medication needs both parental and physician authorization. On the reverse side, is the form to be filled out and signed by you and your child’s physician. This form can then be returned to the center with the proper medication. You are not required to provide this form or any medication to the center, if you do not wish to have it on file. We are providing you with the information and documentation if you desire to do so. ______________________________________________________________________________ 451 Elm Street • North Attleboro, MA 02760 • Tel 508-695-7227 • Fax 508-695-7229 Authorization for Medication
Form 3.8.A

Name of Child: ______________________________________________________________________________ Name of Medication: __________________________________________________ Prescription: Yes No Dosage: ____________________________________________________________________________________ Date(s) medication to be given: ___________________________________________________________________ Times medication to be given: ____________________________________________________________________ Reason for medication: _________________________________________________________________________ Possible side effects: __________________________________________________________________________ Name of Physician: ____________________________________ Phone Number: ____________________________ Directions for storage: _________________________________________________________________________ Special Instructions (i.e., taken with food): __________________________________________________________ ___________________________________________________________________________________________ I, ____________________________ (parent or guardian), give permission to authorized staff members of ScribbleTime A Center for Early Learning, LLC to administer medication to my child as indicated above. □ Copied to the Emergency Evacuation File in the Medicine Cabinet Employee Initials _____ To be filed in the Child’s Record.
______________________________________________________________________________ 451 Elm Street • North Attleboro, MA 02760 • Tel 508-695-7227 • Fax 508-695-7229

Source: http://www.scribbletime.net/Docs/authorization_for_medication.pdf

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