This document is a permission form for a child care facility to administer non-prescription medications to a child. It contains information about the child's name, date of birth, parents' name, doctor's name, and any allergies. The form grants the child care permission to give fever reducers, pain relievers if the child has a fever over 101 degrees for 3 days, and Benadryl in case of allergic reactions. It asks the child's doctor to provide recommended dosages for any over-the-counter medications needed. The form also provides information to parents about safely handing medications directly to staff and guidelines for medication storage and a small fee to cover costs of approved over-the-counter medications.

1. PERMISSION TO ADMINISTER NON-
PRESCRIPTION MEDICATION (O.T.C.) IN CHILD
CARE:
CHILD’S NAME ________________________________________ D.O.B.:
___________________
PARENT/ GURARDIAN’S NAME:
________________________________________________
CLINIC/DOCTOR’S NAME:
_______________________________________________________
ALLERGIES:
______________________________________________________________________
PHYSICIAN:
This form is to grant permission to use Fever Reducer or Pain Reliever (for pain or
fever over 101 degrees for 3 consecutive days without additional medical
authorization) and Benedryl in case of allergic reaction in child care. PLEASE GIVE
RECCOMENDED DOSAGE FOR THESE AND ANY OTHER OTC MEDICATION
NEEDED FOR THIS CHILD IN CHILD CARE:
PARENT:
Please Do NOT bring any medication or creams to care in diaper bags as it is a safety
hazard that the children could potentially get into. Please hand these medicines over
to the care staff directly! Families are welcome to provide a different medicine for
their child, but only under the supervision of the child’s doctor. Medication must be
left at the child care facility in the original container and be placed out of the reach of
children. The following O.T.C. medications (listed below) have been approved for use
by the supervising R.N. at Lady Bug’s Child Care. Each parent is asked to pay three
dollars (per year) to cover their child’s share of the medications. This procedure is
required by the Colorado Department of Human Services.
TYLENOL ________________________________________________
MOTRIN _________________________________________________
BENEDRYL ______________________________________________
OTHER __________________________________________________

2. Special Instructions:
______________________________________________________________________________
Parent Signature/Date:
___________________________________________________________________________
Physician Signature/Date:
________________________________________________________________________