Medication Form - Cleeve Park School

Cleeve Park School - Self-Administer Medication Form
Consent Form to allow Students to carry and administer their own medication in school. A separate form needs to be completed for each medication. If parents are happy for their child to carry and administer their own medication when in school, please complete the following information:
Forename*
Surname*
Date of Birth*

DayMonthYear
Date
Address*
Year Group*
Medication Information
Medical Condition or Illness that the medication is required for (i.e. headache, hay fever, period pain etc)*
Name/Type of medication (as it appears on the container)*
Dosage to be taken (i.e. 2 X 500mg tablet, 1 X Sachet etc)*
Timing of dosage (i.e. as needed, every 4 hours, 1 pill per day etc.)*
Procedures to take in an emergency*
Parental Consent
Signing this form confirms that I deem my child competent to take responsibility for the safekeeping and appropriate administration of their medication as prescribed. My child understands that medication carried by them must not be given to any other pupil.
Name*

Parent Carer First NameParent Carer Last Name
Phone Number*

Area CodePhone Number
Date*

DayMonthYear
Date
Parent Signature*

Clear
Student Signature*

Clear
Should be Empty:

Cleeve Park School - Self-Administer Medication Form