< Back to forms 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