Falls Church – Medication and Emergency Medical Treatment Authorization Form 2016-2016

  • Child's Information

  • MM slash DD slash YYYY
  • CommuniKids Preschool has my permission to administer the following medicine:

  • Note:

    Standards for Licensed Child Day Care Centers require that nonprescription medicine may be given to a child only with the parent's or guardian's written consent. Prescription medicine can be given to a child with the parent's or guardian's written consent AND a physician's prescription.
  • Note:

    For Child Day Care Centers, the effective period must not exceed ten work days unless otherwise prescribed by the child's physician
  • Authorization for Child's Emergency Medical Treatment

  • If my child becomes ill or involved in an accident and I cannot be contacted, I give permission to CommuniKids Preschool, FC to take my child for treatment and I authorize the following hospital or physician to give emergency medical treatment required:

  • I accept responsibility for any necessary expense incurred in the medical treatment of my child, which is not covered by the following:

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