Caring for Our Children: 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: _____________ __________________________________ 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: _____________________________________________________________________ _____________________________________________________________________ FROM: Health care provider: _________________________ Phone: ___________ Address:_____________________________________________________ Date of exam: _________________ Caring for Our Children, 2nd ed. Copyright 2002. National Resource Center for Health and Safety in Child Care 1-800-598-KIDS(5437) info@nrckids.org