Wareham Child Care

508-295-1734

Warehamchildcare.org

MEDICATION CONSENT FORM 102 CMR 7.05(2)(c)

Name of child ____________________________________________________________

Name of medication: ________________________________________________________

Prescription: __ Non-Prescription: Dosage: _______________________________

Date(s) medication to be given: _________________________________________________

Times medication to be given: __________________________________________________

Reasons for medication: _______________________________________________________

Possible side effects: ___________________________________________________________

Name and phone number of prescribing physician: ______________________________________

Directions for storage: ___________________________________________________________

I, _______________________________________, (parent or guardian) give permission

to authorized staff member(s) to administer medication to my child as indicated above.

Parent/Guardian Signature _________________________ Date _____________

Doctor's Signature ________________________________(for non-prescription medication)