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: _____________

__________________________________

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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:

_____________________________________________________________________

_____________________________________________________________________

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FROM: Health care provider: _________________________ Phone: __________

Address:_____________________________________________________

Date of exam: _________________