OTC Consent

Consent to administer an ‘over - the - counter’ (OTC) medicine
- All over the counter (OTC) medicines must be in the original container.
- A separate form is required for each medicine.
- The school is unable to supervise your child's medication unless you complete and sign this form.
- The school has a policy that only staff who hold a current first-aid certificate can administer medications.
CHILD’S NAME*

First NameLast Name
CHILD’S DATE OF BIRTH *

MonthDayYear
Date
NAME AND STRENGTH OF MEDICATION *
EXPIRY DATE *

MonthDayYear
Date
HOW MUCH (DOSE) TO BE GIVEN*
FOR EXAMPLE: One tablet, one 5ml spoonful
AT WHAT TIME SHOULD MEDICATION BE GIVEN?*
please note, students are NOT permitted to leave class to take an OTC medication
REASON FOR MEDICATION *
DURATION OF MEDICINE*
State how long your child needs to take the medication for
Are there any possible side effects that the school needs to know about? If yes, please list them *
Mobile number of parent / carer *
Please enter a valid phone number.
Daytime landline for parent/carer*
Alternative emergency contact name *

First NameLast Name
Alternative Emergency contact number *
Please enter a valid phone number.
Name of child’s GP practice *
Phone Number of child's GP practice *
Please enter a valid phone number.
- I give my permission for the trained staff member to administer the prescribed medicine to my son/daughter during the time he/she is at school. I will inform the school immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.
- I understand that it may be necessary for this medicine to be administered during educational visits and other out of school activities, as well as on the school premises.
- I also agree that I am responsible for collecting any unused or out of date medicines and returning them to the pharmacy for disposal and supplying new stock to the school if necessary.
- The above information is, to the best of my knowledge, accurate at the time of writing.
Parent/carer name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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Consent to administer an ‘over - the - counter’ (OTC) medicine