Non-Prescription Medication Form

Non-Prescription Medication Form

Child’s Name:____________________________________

I hereby give permission to      Jaymi Greenlee    to administer the over-the-counter preparations listed below in accordance with the directions listed on the container.

I understand that these items are to be provided by myself to Jaymi, in new and unopened containers. The child’s name and the date supplied must also be written clearly on the container.

_______ Ointment(s): Desitin & Vaseline

_______ Sunscreen

_______ Insect Repellent

_______ Tylenol (Acetaminophen)

_______ Advil (Ibuprofen)

_______ Other: ________________________

_______ Other: ________________________

_______ Other: ________________________

**I release the above named childcare provider from any liability from administering these products.

Parent Signature/Date: ____________________________________________

Parent Signature/Date: ____________________________________________