Sample Transportation and Medication Authorization

Transportation Authorization

I give permission for my child(ren) to leave my caregiver's home for trips in a car or on foot to child-friendly outings, walks around the neighborhood, playgroups or playdates, etc.

Parent's Signature: __________________________________ Date: ________________



Non-Prescription Medication Record

I hereby authorize [provider], my child's care provider, to use the following products on my child(ren) according to manufacturer or physician's written instructions. I will not hold the above named provider liable for any allergic reactions or other symptoms when the products are used in accordance with these terms.

Parent's Signature: __________________________________ Date: ________________


Please circle Yes or No to designate whether or not you are comfortable with the care provider administering the following products.
Please remember you will be responsible to supply the following products if needed. However the daycare provider often has similar products on hand which might be used periodically if permission is granted below.

Diaper Ointment YES NO
Preferred brand: _________________________
Comments:


Petroleum Jelly YES NO
Preferred brand: _________________________
Comments:


Baby Powder YES NO
Preferred brand: _________________________
Comments:


Baby Lotion YES NO
Preferred brand: _________________________
Comments:


Sunscreen YES NO
Preferred brand: _________________________
Comments:


First Aid Ointment YES NO
Preferred brand: _________________________
Comments:


Teething Tablets YES NO
Preferred brand: _________________________
Comments: ______________________


Numbing Gel YES NO
Preferred brand: _________________________
Comments: ______________________