All medication must be in the original container with the child's name, name of the physician, medication name, and medication directions written on the label. Child Care Center (CCC) Documents and Forms . • One form must be completed for each medication. Multiple medications cannot be listed on one consent form. The below forms and templates are available for providers to use or amend where necessary: Compliance history statement template for a person to be a person in day-to-day charge or a nominated supervisor Compliance history statement template for a prospective family day care educator Excursion risk assessment template INSTRUCTIONS FOR USE . Translated documents and forms were made possible by Grant Number 90TP0046-01-00 from the Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. Consent for Non-Prescription Applications. WRITTEN MEDICATION CONSENT FORM This is a double-sided form Updated 11-04 This form must be completed in a language in which the child care provider is literate. (Over The Counter Medicine Form) Child's Name: _____Date _____ I hereby give _____ permission to apply or give one or more of the following over the counter medications or external preparations, in accordance with the directions for use on the container: Medication Request for Child Care Provider. For more information about licensing forms, call (651) 431-6500; or fax to (651) 431-7643. Permission for Medication Administration at School and Child Care ... Time(s) to my child, according to the Health Care Provider’s signed instructions on the lower part of this form. Authorization for Prescription and Non-Prescription Medication No medication shall be given by child care personnel without the signed permission of the parent or legal guardian. Simply choose the forms that will work the best for you... click, print and use! One form must be completed for each medication. Free child care forms make starting your home daycare easy. Medication Tracking Form. Section A and Section B must be completed for any long-term medication authorizations (those lasting longer than 10 working days). TTY/TDD users can call the Minnesota Relay at 711 or (800) 627-3529. Over-the-counter medication forms are important. You should not use any over-the-counter medications or external preparations without the written consent of parents. Written Medication Consent Form This is a double-sided form • This form must be completed in a language in which the child care provider is literate. Medication Authorization Form For Prescription and Non-prescription Medications VDSS Division of Licensing Programs Model Form INSTRUCTIONS: Section A must be completed by the parent/guardian for ALL medication authorizations. Stepping Stones to Caring for Our Children – Selecting an Appropriate Sanitizer or Disinfectant. 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