Someries Infant School and Early Childhood Education Centre's Parental Agreement for the school to administer medicine

1
Your child's name* This field is required.
First Name
Last Name
2
Your child's date of birth* This field is required.
Date
Day
Month
Year
3
Your child's class* This field is required.
Please Select
Please Select
Windsor
Lancaster
Warwick
Gosford
Tintagel
Edinburgh
Durham
Cardiff
York
The Compass
The Link
The Lighthouse
4
Medical condition or illness* This field is required.
5
Name or type of medicine* This field is required.As described on the container
6
Does the medicine provided require refrigeration?* This field is required.
YESNO
7
Expiry date* This field is required.As indicated on the container
Date
Day
Month
Year
8
What time do you require medicine to be administered to your child?* This field is required.Please note that we can only administer medicine once per school day.
12
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12
Hour
00
00
01
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59
Minutes
PM
AM
PM
9
On what date should the school BEGIN administering medication?* This field is required.
Date
Day
Month
Year
10
On what date should the school STOP administering medication?* This field is required.
Date
Day
Month
Year
11
Please explain dosage and method instructions.* This field is required.These should fall in line with those provided by the dispensing pharmacist.
Huge
Large
Normal
Small
Ok
Ok
12
Are there any special precautions or other instructions the school needs to be aware of when administering the medicine provided?* This field is required.
No
Other
13
Are there any side effects of the medicine provided that the school needs to be aware of?* This field is required.
No
Other
14
Can the medicine be administered by your child?* This field is required.
YESNO
15
What procedures should be undertaken in case of an emergency?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
16
Your name* This field is required.
First Name
Last Name
17
Your relationship to the child named in this Agreement* This field is required.
18
Emergency contact telephone number* This field is required.
19
Your email address* This field is required.You will receive a copy of this submission via email
20
To the best of my knowledge, the information provided in this form is accurate at the time of submission.
YESNO
21
I give consent for staff at Someries Infant School and Early Childhood Education Centre to administer medicine in accordance with the information provided by me in this form and the school's policies and guidelines.
YESNO
22
I will inform the school immediately if there is any change in dosage or frequency of the medicine or if the medicine is stopped.
YESNO
23
I understand that I will be required to collect my child's medicine from the School Office on the date the requirement to administer this ends.
YESNO
24
Signature* This field is required.
Clear
25
Date and time of submission of this Parental Agreement* This field is required.
Date
Day
Month
Year
9
1
2
3
4
5
6
7
8
9
10
11
12
Hour
28
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
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22
23
24
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27
28
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40
41
42
43
44
45
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49
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51
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53
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57
58
59
Minutes
AM
AM
PM
26
Privacy Notice* This field is required.
Should be Empty: