APPENDIX W: PERMISSION FOR MEDICAL CONDITION TREATMENT

Permission for Medical Condition Treatment

Parent or Guardian signature indicates permission for child care provider to follow these instructions:

___________________________________________

(Parent Signature)

TO: Facility name _______________________________ Phone: ___________

Address: __________________________________ Fax: _____________

__________________________________

Child's name: _____________________________ Date of Birth: _________________

Address: _____________________________________________________________

Medical condition(s) of concern: ____________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Signs and/or symptom(s) to watch for: ________________________________________

Medications: ______________________________ Dose: ______________________

How given: _______________________________ When given? _________________

Possible side effects: _____________________________________________________

Temporary program adaptations: ____________________________________________

______________________________________________________________________

When to call parent/health provider regarding symptoms or failure to respond to treatment: _____________________________________________________________________

_____________________________________________________________________

When to consider that the condition requires urgent care or reassessment:

_____________________________________________________________________

_____________________________________________________________________

FROM: Health care provider: _________________________ Phone: ___________

Address:_____________________________________________________

Date of exam: _________________