Authorization to Dispense External Preparations 590-1-1-.20(1) Parental Authorization. Except for first aid, personnel shall not dispense prescription or non-prescription medications to a child without specific written authorization from the child's physician or parent. Such authorization will include, when applicable, date; full name of the child; name of the medication; Prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of parent. I give ________________________________________, permission to apply one or more of the following topical ointments/preparations to my child in accordance with the directions on the label of the container. _____ Baby Wipes _____ Band-aids _____ Neosporin or similar ointment _____ Bactine or similar first aid spray _____ Sunscreen _____ Insect Repellent _____ Non-Prescription ointment (such as A & D, Desitin, Vaseline) _____ Baby Powder Other (please specify) _________________________________________________________________ Parent/Guardian Name: _______________________________________ Parent/Guardian signature: ____________________________________ Date: ____________ *center should maintain in file child’s
Authorization to Dispense External Preparations 590-1-1-.20(1) Parental Authorization. Except for first aid, personnel shall not dispense prescription or non-prescription medications to a child without specific written authorization from the child's physician or parent. Such authorization will include, when applicable, date; full name of the child; name of the medication; Prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of parent. I give ________________________________________, permission to apply one or more of the following topical ointments/preparations to my child in accordance with the directions on the label of the container. _____ Baby Wipes _____ Band-aids _____ Neosporin or similar ointment _____ Bactine or similar first aid spray _____ Sunscreen _____ Insect Repellent _____ Non-Prescription ointment (such as A & D, Desitin, Vaseline) _____ Baby Powder Other (please specify) _________________________________________________________________ Parent/Guardian Name: _______________________________________ Parent/Guardian signature: ____________________________________ Date: ____________ *center should maintain in child’s file
Enrollmentpackage.docx