Medical Authorization Form

Authorization To Give Medication

  • Medication Authorization Form
    For Prescription and Non-prescription Medications

  • Little Lights Childcare Center has my permission to administer the following medication:

  • (Start Date)
  • (End Date)
  • E-Signature

  • By digitally signing this form, you agree that you are authorizing this child to be given the specified medication for short term authorizations, and are agreeing for Little Lights Childcare Center to process this document under the Virginia Department of Social Services. You also authorize us to place your legal signature under the VDSS Division of Licensing Programs Model Form that you are currently filling out now.

    NOTE that Section B must be filed under a written note from your child's physician, and CANNOT be entered in online.