Request to school for administration of medication

Request to school for administration of medication

The school will not give your child medicine, or allow self-administration of medication, unless you have completed and signed this form, and the Headteacher has given you written comfirmation of their agreement.
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: