Parental/Carer consent to administer a prescribed medicine

Parental/Carer 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 on pharmacy label.
- A separate form is required for each medicine.
- Students with Anaphylaxis must carry x2 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.
DETAILS OF PUPIL
Name*

First NameLast Name
Condition or illness*
Class/Form*
MEDICATION
Medication/Type of Medication (as described on the container)*
How long will your child take this medication:*
Date dispensed*

DayMonthYear
Date
Medication expiry date*

DayMonthYear
Date
Full directions for use:
Dosage and method*
Timing 01*

Hour Minutes

AM/PM Option
Timing 02 (If a 2nd dose is required)

Hour Minutes

AM/PM Option
Special Precautions
Side Effects
Medication will be stored in a lockable cabinet in first aid.

Student will self administrate medication
Procedures to take in an Emergency:
CONTACT DETAILS
Family Contact 1 Name:*

First NameLast Name
Home (landline)
Please enter a valid phone number.
Mobile
Please enter a valid phone number.
Relationship
Family Contact 2 Name:

First NameLast Name
Phone Number (work)
Please enter a valid phone number.
Home (Landline)
Please enter a valid phone number.
Mobile
Please enter a valid phone number.
Relationship
I understand that i must deliver the medicine personally to (agreed member of staff) and accept that this is a service which the school is not obliged to undertake.
Date*

MonthDayYear
Date
Relationship to pupil
Signature(s)

Clear
Should be Empty: