Admissions Application.

Complete this form for admissions consideration.

Step 1 of 4

  • Child Information

  • Parent Information

  • Emergency Information

  • Authorized Staff to Administer Prescription Medications

    The program will administer prescription medications in accordance with the physician's or other prescriber's instructions and in accordance with the standards of practice in the MAT training. Only a provider who has successfully completed theMAT training or has appropriate licensure to administer prescription medicat ions and is listed as a medication administrator in the Program's Decision Regarding Medication Plan will be permitted to administer prescription medications in my program.

    I understand that any individual listed in this section as a medication administrator is approved to administer prescription medications using the following routes: topical, oral, inhaled, eye, and ear, medication patches and epinephrine using an auto-injector device.

    I understand that if a child in my program requires prescription medication to be administered rectally,vaginaJly, by injection or by another route not listed above, I will follow the procedures outlined in the MAT training for children with special health care needs.

    I understand that to be approved to administer prescription medication, all individuals listed in my PROGRAM'S DECISION REGARDING MEDICATION plan (unless the individual is licensed to adminis-ter prescription medications) must have a valid:

    • Medication Administration Training (MAT) certificate;
    • CPR certificate which covers all ages of the children my program is approved to care for as listed on my registration/ license; and
    • First aid certificate which covers all ages of children my program is approved to care for as listed on my registration/license.
  • Person to be Contacted if Parent(s) Cannot Be Reached