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first-aid-kit

Request to Administer Emergency, Life Saving Medication

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12Questions
  • 1

    EPI-PEN OR OTHER LIFE SAVING MEDICATION

    If your child is prescribed emergency, life saving medication such as an epi-pen please bring the medication in to school in the original container with the prescription label attached. You will must complete this form before we can administer any medication. Please note we cannot administer other medication or over the counter medications including cough lozenges and painkillers.

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    Note: Medicines must be the original container as dispensed by the pharmacy with the child's name on.  

    If more than one medicine is to be given, a seperate for should be completed for each one.

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  • 5
    e.g. EPIPEN (epinephrine injection, USP) 0.3 mg
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  • 6
    e.g. 01-10-2022
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    Pick a Date
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  • 8
    Please write NONE if no other instructions.
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  • 9
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  • 10

    The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school/setting staff administering medicine in accordance with the school/setting policy.

    I will inform the school/setting immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.

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