Childcare Medication Log

MEDICATION LOG

55 Pa. Code 3270.133; 3280.133; 3290.133

Dates for Administration:

Date
Date

I give permission to administer medication to my child as stated above.

FACILITY STAFF COMPLETE THIS SECTION

FACILITY

This information is confidential and may not be shared or released without the parent’s written permission.

CY 862 10/04

Sending

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