Free printable medication log and permission form.

One sheet per child, per medicine. The family fills in the top, and staff write down each dose they give.

It prints at the top of the form.

Medication permission and log

Program
Child’s name
Child’s date of birth

Filled in by the family

Medicine name
Reason for the medicine
Dose
How it is given
Times to give it
Start date
End date
Prescribed by
Side effects to watch for
How to store it

I give permission for staff to give this medicine to my child as written above.

Parent or guardian signature
Date
Doses given
DateTimeDose givenGiven byWitnessNotes

Free printable form from bloomily.app/tools/forms

How to use this form

  1. Take medicine only in its original container, labeled with the child’s name.
  2. Check the label against the permission at the top before every dose.
  3. Write each dose right after you give it.
  4. Tell the family about each dose at pickup.
  5. Keep the sheet with the child’s records when the medicine ends.

Check your state’s rules

Many states set rules for giving medicine in care, such as written permission and original containers. Check your state’s rules for what this log must show.

Find your state’s licensing page

Do this in Bloomily

In Bloomily, each medicine has its permission, dose and times on file. Staff mark each dose as given, and the family can be told in the app.

See health and safety

More free forms

Questions, answered

Do we need written permission to give a child medicine?

Most states require it before staff give any medicine. The top of this form is that permission. Check your state’s rules.

What is the witness column for?

Some programs have a second staff member check each dose. Leave it blank if yours does not.

See it with your name on the door.

Get started

or book a demo

One flat price per location, never per child. $199 a month billed yearly ($2,388), or $249 month to month. Free for home daycares up to 18 children. Every fee is on the pricing page.

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