KTC Primary School Medication Consent Form

Medication Consent Form

Please complete this form to grant permission for staff at Kesser Torah College Primary School to administer medication to your child.
Student Details
Student Name*

First NameLast Name
Student's Date of Birth*

DayMonthYear
Date
Student's Class*
Student's Allergies (write N/A if none)*
Medication Details
What is the purpose of the medication?*
What is the type of medication?*

Over the counterPrescription medication
Name of Medication*
Strength of Medication*
How many times a day is the medication to be administered at school

Once a dayTwice a dayThree times a day
Time to be administered*

Hour Minutes

AM/PM Option
Second time to be administered

Hour Minutes

AM/PM Option
Third time to be administered

Hour Minutes

AM/PM Option
Dose to be administered*
Possible side effects (write N/A if none)*
Prescribing Doctor Details
Prescribing Doctor*

First NameLast Name
Doctor's Phone*
Please enter a valid phone number.
Doctor's Address*

Street Address

Street Address Line 2

CityState

Post Code
Parent Consent
I hereby grant permission for staff at Kesser Torah College to givechild's name* the above named medication as prescribed. I agree to provide the medication in the original packaging, properly labeled by the chemist. I agree to inform the school immediately of any changes to the medication dose.
Parent Name*

First NameLast Name
Parent Email*
example@example.com
Parent Signature*

Clear
Should be Empty:

Medication Consent Form