Text Box: PERMISSION FOR SONSHINE CENTER PRESCRIPTION MEDICATION Name of Child: ____________________________________________ Age:_________________ Primary Health Care Provider: _______________________________________________________ Medication: _______________________ Dosage: ________________ Route: ________________ Purpose of Medication: _____________________________________________________________ Time of Day Medication is to be Given: ________________________________________________ Possible Side Effects: ______________________________________________________________ Anticipated number of days it needs to be given at child care facility: _________________________ __________________________________________________ _________________ Signature of Person with Prescriptive Authority Date Parent/Guardian I hereby give my permission for ___________________________ to take the above prescription medication at the childcare facility as ordered. I understand that it is my responsibility to furnish this medication. ______________________________________________ ___________________ Parent/Guardian Signature Date NOTE: The prescription is to be brought to the child care facility in its original pharmacy container appropriately labeled by the pharmacy or person with prescriptive authority. Text Box: PERMISSION FOR SONSHINE CENTER PRESCRIPTION MEDICATION Name of Child: ____________________________________________ Age:_________________ Primary Health Care Provider: _______________________________________________________ Medication: _______________________ Dosage: ________________ Route: ________________ Purpose of Medication: _____________________________________________________________ Time of Day Medication is to be Given: ________________________________________________ Possible Side Effects: ______________________________________________________________ Anticipated number of days it needs to be given at child care facility: _________________________ __________________________________________________ _________________ Signature of Person with Prescriptive Authority Date Parent/Guardian I hereby give my permission for ___________________________ to take the above prescription medication at the childcare facility as ordered. I understand that it is my responsibility to furnish this medication. ____________________________________________ ___________________ Parent/Guardian Signature Date NOTE: The prescription is to be brought to the child care facility in its original pharmacy container appropriately labeled by the pharmacy or person with prescriptive authority. Text Box: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -