ADMINISTERING MEDICATION CONSENT FORM
This form excludes students with current Anaphylaxis, Allergy or Asthma actions plans that clearly state the required medication and their dosages. Please note: WLC can only administer medication with verbal AND written authority of parents/guardians.
Student Name
*
First Name
Last Name
Year Level
*
Campus
*
Dimboola
Horsham
Nhill
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Medical History
*
Rows
Yes
No
If Yes, Please Explain
Does your child have any anaphylaxis?
Does your child have any allergies?
Does your child have a serious medical condition?
Do you authorise and consent staff at WLC to administer Pain Relief Medication to {studentName:first}?
*
Yes
No
Do you authorise staff at WLC to administer the recommended dose of Panadol/Paracetamol to {studentName:first}?
*
Yes
No
Do you authorise staff at WLC to administer the recommended dose of Nurofen/Ibuprofen to {studentName:first}?
*
Yes
No
Do you understand that you will recieve a phone call before Pain Relief Medication is administered to {studentName:first}?
*
Yes
No
Have you provided accurate and updated information about {studentName:first}'s health needs and management of medical conditions?
*
Yes
No
Other
Do you agree to make arrangements to collect {studentName:first} if they become unwell and/or need further care?
*
Yes
No
Signature: {parentguardianName}
*
Date
-
Day
-
Month
Year
Date
Submit
Submit
Should be Empty: