The Children’s Nook Medicine Form

I give my permission to _________________________ to administer prescription/non-prescription medication to my child, ______________________ as listed below. I agree to supply the operator of this facility with the medication, which is to be administered to my child. I understand any medicine to be administered must be in its original container and that the facility cannot administer the first dosage of the day. Also, I understand a doctor’s note for prescription/non-prescription medication is necessary.

Signature_____________________________________________ Date____________________

(Parent or Legal Guardian)

Note: A copy of this permission form must be on record for all children to whom prescription/non-prescription medication is to be administered.