Consent to Administer Medication (version Sep 26)

Consent to Administer Medication

For prescribed medication to be administered within school hours
Our Medications in School Policy states that staff can administer medication to pupils during school hours.

The school will not give your child medication unless this form has been completed.

Therefore please ensure that this form is submitted before your child arrives at school.
Child’s Name

First NameLast Name
Child's date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Is this medication an asthma inhaler?
Medication Name, as it appears on the label (including strength)
Expiry date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Amount sent to school
Does the medication need to be stored in a fridge?
Date prescribed by a GP

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Is this an acute medicine (to take for less than 30 days) or an ongoing medicine (longer than 30 days or repeat prescription)
Name of GP
GP telephone number
Please enter a valid phone number.Format: 00000 000 000.
What condition has this medication been prescribed for? Please tell us the name of the medical condition, where known (e.g. asthma, eczema or epilepsy), rather than just the symptoms (e.g. pain or a cough).
Diagnosis and brief description of symptoms
Last time medication was given

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour MinutesAM/PM Option
Dosage to be given
Eg. 2 tablets, 15 ml, 2 drops, 1 puff etc.
How should this medication be given or applied? Please provide any instructions we need to follow, including when the medication should be given or applied and any special requirements.
i.e. With a glass of water, apply a thin layer to affected areas as needed if symptoms occur, take with food etc
When should medication be given?
Time of first dose (if applicable)

Hour Minutes

AM/PM Option
Time of second dose (if applicable)

Hour Minutes

AM/PM Option
Time of third dose (if applicable)

Hour Minutes

AM/PM Option
Time of fourth dose (if applicable)

Hour Minutes

AM/PM Option
Does the medication need to be sent home at the end of the day?
Additional information
Chronic Medicated Conditions

Conditions that are expected to last more than 30 days
What are the Symptoms and/or triggers for this condition?
i.e. Breathless after exercise, leg pain when walking, rash etc.
Does your child need additional support and/or aids for this condition?
i.e. wheelchair, splint, continence products, special cutlery, staff intervention etc. Enter N/A if none required.
Emergency actions (if applicable)
What does an emergency situation look like for this condition? What action(s) should be taken in the event of an emergency situation, relating to this condition? Enter N/A if non required.
ASTHMA INHALERS

Pupils who have been prescribed an inhaler must ensure they bring it to school each day. However, the school has a small supply of spare inhalers which can be used, with your consent, should the child forget their own. (Please note that the inhalers are sanitised between uses).
I consent to my child using a school inhaler if necessary.
Terms and Conditions
- Medication must be in the original named box/bottle and always with the pharmacy label showing the child’s name, DOB, dose, date and storage instructions.
- A measured medicine spoon / syringe should be supplied with the medication (if applicable).
- Staff must be given all of the information required to insure the well-being of the child.
- Your child should be given at least one dose at home and monitored for any unwanted reactions before sending the medication into school.
- School should be informed immediately if there is a change to this medication.
- In the absence of instructions regarding specific emergency actions, school will follow their policy regarding First Aid and Emergency Services policy can be viewed on the Pennine View School website).
- If your child is diagnosed with a new medical condition you must notify school immediately.
CONSENT
Parent Name

First NameLast Name
Contact telephone number
Please enter a valid phone number.Format: 00000 000 000.
Agreement to terms and conditions
Signature
Should be Empty:

Consent to Administer Medication

Chronic Medicated Conditions

ASTHMA INHALERS

Terms and Conditions

CONSENT