Medication Release Form
Diana's Lil' Darlings In Home Family Childcare
Where Children Come First
Child's Name ___________________________ Date of Birth ______________________________
Name of Medication ______________________________________
Dosage __________ Frequency ____________________ Length of time to be given ___________________
Physicians Authorization _____________________________________________
Date _____________
If this is an "as needed" medication;
Symptoms that would indicate the medication would be given ______________________________________
Length of time the medication is allowed to be given on an "as needed" basis _________________________
The maximum amount of medication allowed in a 24 hour period.
The prescribed medication shall be in the original container. Please attach a medical information sheet obtained from your physician or pharmacy.
Parents Signature __________________________ Date _________________________
