KidZone Hourly Playcare - Medication Authorization

Kidzone requires parental consent for any child requiring medication, including epipens or
inhalers, while at the program. Kidzone staff is required to observe and record all use of
medication by a child while attending the program. Please ensure that all medication is in its
original container. Please list one item per sheet with full usage/special instructions.

Child's Name (required)

Name of Medication

Prescription Number

Start Date

End Date

Time to be Taken

Amount to be Taken

Expiry Date on Medication

Special Instructions

By signing below you are giving permission for a Kidzone staff member to administer the above
medication to your child according to labeled directions on the original medication container.

Parent/Guardian's Name

Date

Signature

SELF ADMINISTRATION OF MEDICATION

In some cases, children are able to administer their own medication. In all cases, program staff
is required to observe children taking medication.

Does your child have permission to self-administer their medication?
yesno

Parent/Guardian's Name

Date

Signature