Parental agreement for school/setting to administer medicine
Use this form to provide medicine administration details and parent/carer acknowledgements for a school or setting.
Medication and child details
School/setting name
*
Child name
*
Date of birth
*
-
Month
-
Day
Year
Date
Class
Medical condition or illness
*
Name/type of medicine as shown on the container
*
Date dispensed
-
Month
-
Day
Year
Date
Expiry date
-
Month
-
Day
Year
Date
Dosage and method
*
Timing
*
Special precautions
Safety, administration, and emergency information
Possible side effects the school/setting should know about
Can the child self-administer the medicine?
*
Please Select
Yes
No
Emergency contact name
*
Daytime telephone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to child
*
Parent/carer acknowledgements and signature
Acknowledgement statements
*
I understand that I must deliver the medicine personally to the agreed member of staff
I understand that I must notify the school/setting of any changes in writing
Date
*
-
Month
-
Day
Year
Date
Parent/carer signature
*
Relationship to child
*
Parent/carer name
*
Submit
Submit
Should be Empty: