NonPrescriptionMed

NON-PERSCRIPTION MEDICATION

I hereby authorize Julie Ryan, my child's day care provider, to use the following products on my child according to manufacture or physician's written instructions. I understand that this form is valid for the entire time my child is in the care of this provider. I understand that it is my responsibility to contact the provider should any of the following information change.
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CHILD'S NAME: _______________________________ DATE: _________________________

Diaper Wipes
Diaper Ointements
Baby Lotion
First Aid Ointments
Vaseline
Insect Spray
Sunscreen
Ipecac Syrup
Tylenol (Verbal)

YES ~ NO            Brand: ______________________________
YES ~ NO            Brand: ______________________________
YES ~ NO            Brand: ______________________________
YES ~ NO            Brand: ______________________________
YES ~ NO            Brand: ______________________________
YES ~ NO            Brand: ______________________________
YES ~ NO            Brand: ______________________________
YES ~ NO            Brand: ______________________________
YES ~ NO            Brand: ______________________________

PARENT'S SIGNATURE: _________________________________ DATE: ________________

PROVIDER'S SIGNATURE: _______________________________ DATE: ________________

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