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Kansas Department of Health and Environment

CCL.027

Rev. 3/2017

Bureau of Family Health

Child Care Licensing Program

1000 SW Jackson, Suite 200

Topeka, KS 66612-1274

Phone: 785-296-1270 Fax: 785-559-4244

Website:

Authorization for Dispensing Medications to Children and Youth

Long-Term Medications (Prescription and Non-Prescription)

Prescription medications must be in their original containers labeled with the child’s or youth’s first and last name, the date the

prescription was filled, the name of the licensed physician or licensed nurse practitioner who wrote the prescription, the expiration

date of the medication, and specific and legible instructions for administration and storage of the medication. Administer the

medication according to the instructions. Non-prescription medications can be given by permission and direction from the parent,

guardian or legal custodian based on general advice received from the child’s or youth’s physician. Administer nonprescription

medication from the original container labeled with the first and last name of the child or youth and according to the instructions on

the label. A record of administration must be kept.

______________________________________________________________________________________________________

First and Last Name of Child or Youth

______________________________________________________________________________________________________

Name of Medication (only one medication per authorization)

Prescription OR Non Prescription

_______________________________________________________________________________________________________

Reason for Medication

_______________________________________________________________________________________________________Do

Time to be Given

Start Date

Stop Date**

_______________________________________________________________________________________________________

Name of Licensed Physician or Nurse Practitioner prescribing the medication

Phone # of Physician

I allow the above medication to be given to my child or youth by the child care provider/staff member or school age program staff

member.

_______________________________________________________________________________________________________

Parent’s Signature

Date Signed

**Stop date not to exceed one year from the start date. A new authorization is to be completed any time the medication, dosage, times to be given, or instructions

from the parent or health care provider change from the information included on this form. Additional copies of this form may be attached to this page if more

space is needed to record the administration of the medication for up to one year if there are no changes in instructions. Above information must be completed

on each page but the parent’s signature is required only once per year.

THIS FORM IS TO BE USED TO DOCUMENT ADMINISTRATION OF ONLY THE MEDICATION IDENTIFIED ABOVE. Provider or staff member

to note any comments or remarks about the child’s or youth’s appearance and/or condition on the back of the form.

Date

Time

*Initials

Date

Time

*Initials

Date

Time

*Initials