Fill it out online

Medication Permission

Required by the State of Utah for any medication — prescription or over-the-counter — left with the provider. One form per medication. Sara cannot give your child any medication without a current, signed permission form on file.

Complete one form for each medication. We'll email a copy to you and to Sara. The medication itself must be brought in its original container labeled with your child's name.

Child

Child's full name *Date of birth *

Medication

Medication name *Reason for medication / condition being treated *Dose (e.g., 5 mL, 1 tablet) *Route (e.g., oral, topical, inhaled) *When to give it (times and/or conditions) *Start date *End date (or expected duration) *Possible side effects to watch for

Prescribed by

Prescribing provider (if applicable)Prescriber phone (if applicable)

Parent / guardian

Parent / guardian name *Email address *Phone number *

Signature

Type your full legal name as your signature *Date signed *

By submitting, I acknowledge:

I authorize Country Lane Early Learning to give the medication listed below to my child as described.
The medication will be provided in its original container, labeled with my child's name and current dosage instructions.
I will notify the provider immediately of any change in the medication, dose, or schedule.

Your information is sent securely to Sara. We never share it.