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Get NC 12A-r 1999-2024

R my child to be given the following medication: Child’s Name: Expiration Date: Name of Medication: Dosage: † Refrigerate Dates to be Given: Times to be Given: ( ) ( ) ( ) Special Instructions: Possible Reactions: Parent’s Signature: Monday Date: Tuesday Wednesday Thursday Friday Medication: Dosage: Date: Times: Facility Staff’s Signature: *** RETURN MEDICATION TO PARENT UPON COMPLETION *** Revised Sample 9/99 Child Care Facility Name_________________________________________.

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  • REFRIGERATE
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