Medication Form

REQUEST FOR ADMINISTRATION OF MEDICATION IN SCHOOL

All medication must be given to the school office in the original packaging and a separate form completed for each medicine

Non-prescribed medication will not be accepted unless prior agreement has been given by the Headteacher
Name of Child*
Year and class*
Date of Birth*

MonthDayYear
Date
Medical condition or illness*
Name of medicine (as shown on the container)*
Date Dispensed*

MonthDayYear
Date
Expiry date*

MonthDayYear
Date
Dosage and method*
When to be given*
Any side effects that the school needs to know about*
YesNo
YesNo
My child's reliever inhaler should be held in the classroom to be administered as requiredMy child has my permission to carry his/her reliever inhaler for self-administration and I understand that it is my child's responsibility to notify their teacher or the school office when it has been used so it can be noted on his/her Medication Record.
In accordance with the London Schools’ guide for the care of children and young people with asthma, we ask thatan Asthma Action Plan is completed for all children diagnosed with this condition. Forms are available from the office or can be downloaded from https://tinyurl.com/Asthma-Care-Plan
I do not give consentI give consent
Anaphylaxis
I do not give consentI give consent
Parents/Guardians' name*
GP Surgery and telephone number*
The obove information is, to the best of my knowledge, accurate at the time of writing and I give consent to school staff administering medicine in accordance with the school policy. / will inform the school immediately, in writing, if there is any change in dosage or frequency or if the medication is stopped.
Parent's signature*

Clear
Print name*
Date*

MonthDayYear
Date
REGULAR MEDICATION WILL BE SENT HOME AT THE END OF THE SUMMER TERM A NEW FORM IS REQUIRED EACH ACADEMIC YEAR
Should be Empty: