Circle Of Life Learning Center
Parent’s Authorization:

Dr. Melta Sprinkles/Circle of Life
Provider and/or Facility

Please administer the following medication to:
Name of Child

Prescribing Physician: ______________________________________
Prescription Number:_______________________________________
Name of Medication: _______________________________________
Dosage: _________________________________________________
When to give: ____________________________________________
Continue Medication Until: _______________Date:_______________

Medicine must be in its original container with the child’s name clearly written on it.  Ask pharmacist for 2 original containers (one to
keep here and one for home, so you don’t forget to bring or take home).

Signature of Parent:____________________________date:___________

Caregiver’s Record of Medication dosages:
Amount        Time        Date        Amount        Time        Date

Medication returned to child’s parent _______________ or thrown away _______.
                                  Date                                Date        
Parents, how are we doing?
Your feedback is important to us! Please take the time to let us know if we are meeting your goal in providing high quality care.  
Feel free to make this anonymous. We need your thoughts and suggestions, not your identity. Please elaborate on each question as
you wish. We really DO take your comments seriously.

1.        Do you have peace of mind about your child’s care when he/she is in our care?

2.        Do you feel comfortable recommending our care to other parents?

3.        Do you feel adequately informed about our policies, procedures and practices?  If not, please let us know where we are
being unclear.

4.        Which aspects of our program impress you the most?

5.        Which aspect of our program confuses and/or frustrates you the most?

6.        Do you and your child feel welcomed daily?  Do you feel we treat all parents and children fairly, without bias or favoritism?  

7.        Are we approachable for your concerns or suggestions?

8.        Do we perform as we value our role in your child’s life?  Do you feel we care about your child and notice when they are not
in attendance?

9.        Are parent-teacher conferences helpful?

10.        Do you feel comfortable participating in our program in any way you wish? (ie observation, snack visits, story-time, drop in
visits, parent-teacher meetings)

11.        Which methods of program communication are valuable to you?

12.        Do you have suggestions for improving our program or services?

13.        How has your child benefited from being in our care?

14.        How have you benefited from our program?

15. List any concerns we should address, or suggestions for improvement.
Parent Survey
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1705 Temple Hall Hwy.
Granbury, Texas 76049
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