Consent to Administer a Prescribed Medicine
All prescribed medicines must be in the original container as dispensed by the pharmacy, with the child's name, the name of the medicine, the dose and the frequency of administration, the expiry date and the date of dispensing included in the pharmacy label.
A separate form is required for each medicine.
Students with Anaphylaxis must carry two EpiPen's at all times
Students with Asthma should keep a “spare” inhaler in the medical room at all times, regardless of them carrying one on their person.
The school is unable to supervise your child's medication unless you complete and sign this form.
The school has a policy where only First Aid trained staff can administer prescribed medication.
CHILD’S NAME
*
First Name
Last Name
CHILD’S DATE OF BIRTH
*
-
Day
-
Month
Year
Date
NAME AND STRENGTH OF MEDICATION
*
For example Paracetomol 100mg
EXPIRY DATE
*
-
Day
-
Month
Year
Date
HOW MUCH (DOSE) TO BE GIVEN
*
FOR EXAMPLE: One tablet, one 5ml spoonful
AT WHAT TIME SHOULD MEDICATION BE GIVEN
*
REASON FOR MEDICATION
*
DURATION OF MEDICINE
*
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
I give permission for my son/daughter to carry their own Salbutamol Asthma inhaler/Adrenaline auto injector pen for anaphylaxis or Asthma
*
YES
NO
NOT APPLICABLE
I give permission for my son/daughter to carry their own salbutamol asthma inhaler and use it themselves
*
YES
NO
NOT APPLICABLE
I give permission for my son/daughter to carry their own medicine (stated above) and use it themselves
*
YES
NO
NOT APPLICABLE
I give permission for my son/daughter to carry their own medicine (stated above) and administered by a member of staff
*
YES
NO
NOT APPLICABLE
Mobile number of parent / carer
*
-
Area Code
Phone Number
Daytime landline for parent/carer
Alternative emergency contact name
*
First Name
Last Name
Alternative Emergency contact number
Please enter a valid phone number.
Name of child’s GP practice
*
Phone Number of child's GP practice
*
-
Area Code
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 Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
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