Child’s Name: Date of Birth: ……………………………………………………………… …………………………………………… Educator: …………………………………………………………………………………………... To be completed by the parent/guardian To be completed by the Educator when administered Name of the Last To be Dosage to be Method of Signature of Name of the Medication Dosage Method of Name of Signature of medication administered administered administered administration parent/guardian medication administered administered administration Educator Educator (or administering administering circumstances to be administered) Time Date Time Date Time Date
Child’s Name: ……………………………………………………………… Date of Birth: …………………………………………… Educator: …………………………………………………………………………………………... To be completed by the parent/guardian To be completed by the Educator when administered Name of the medication Last administered To be administered (or circumstances to be administered) Dosage to be administered Method of administration Signature of parent/guardian Name of the medication Medication administered Dosage administered Method of administration Name of Educator administering Signature of Educator administering Time Date Time Date Time Date