Unit 11.9 Sample of authorization
Specific Field Trip Authorization SAMPLE
I, ___________________________________ give__________________________________________, (Parent’s name) (Care Provider’s name)
and her employees (if applicable), permission to take my child,__________________________________ ( Child’s name)
to _______________________________ . This includes transportation by ________________________ (Specific location)
This permission is granted only if my child will be appropriately restrained in any vehicle and for this trip only.
______________________________________ _______________________
Parent Signature Date
______________________________________
Care Provider Signature
Medication Authorization Form SAMPLE
Medication will only be administered if it has been prescribed by a registered medical practitioner and is in its original container.
I, __________________________________, authorize _______________________________________ (Parent’s name) (Care provider’s name)
to administer ________________________________ to my child ______________________________ (Medication) (Child’s name)
with the following instructions:
Dosage: ______________________________________________________________________ Time(s): ______________________________________________________________________
Special Instructions (ie: on full/empty stomach, etc.):
____________________________ ________________________________________________________
Possible Side Effects: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________ ________________________________
Parent Signature Date
Time and date administered:
Date Time Provider Initials
Photograph Release/Permission Form SAMPLE
This is an agreement between child care provider ___________________________________________ (child care provider)
and parent ________________________________________. (parent/gardian)
I consent to the use of any photographs in which I or my child(ren) appear, taken by
________________________________________ on _________________________________ . (Child Care Provider) (date)
For use in the ________________________________________________________ (Purpose of use).
I give full copyright and permission to use my photograph in the above named production and any subsequent presentation of that production and in any subsequent promotional materials such as newsletter and brochures.
______________________________________________________ (Signature of person/guardian in photo)
______________________________________________________ (Witness)
______________________________________________________ (Date)
Skin Care Product Consent Form SAMPLE
This is an agreement between child care provider ________________________________________ (child care provider)
and parent ________________________________________. (parent)
I hereby give the child care provider my consent to apply ___________________________________ to my child’s skin when appropriate or necessary.
Child’s Name: __________________________________________
______________________________________________________ (Parent’s Signature)
______________________________________________________ (Child Care Provider’s Signature)
______________________________________________________ (Date)