Prescribed Medicines Permission Form

Class/Tutor Group:*

Child's name:*

First NameLast Name

Date of Birth*

DayMonthYear

If your child requires regular medication, the school requires you to provide authorisation to dispense the medicines.

Medications MUST be handed to the nurse by a responsible adult (parent or helper). No medications will be accepted from students.

Remaining medication will not be sent home with a child – a parent or carer will need to collect it from our medical room.

Medical Problem*

Medication Details*

Time of last dose *

Duration of Prescription*

Last date medicine to be administered *

Prescribing Doctor Name*

Prescribing Doctor Surgery*

Prescribing Doctor Phone number*

I authorize Discovery Bay International School to administer the following medicines to my child:

I authorize Discovery Bay International School to administer the above listed medicines to my child:*

I have read and understood the attached Prescribed Medicines Statement and accept them fully.

I have read and understood the attached Prescribed Medicines Statement and accept them fully.*

The name of medicine, date (prescribed by a doctor within 7 days), student’s name, dosage and route of administration is marked clearly on each medication bag/bottle.

The name of medicine, date (prescribed by a doctor within 7 days), student’s name, dosage and route of administration is marked clearly on each medication bag/bottle.*

Parent/Guardian*

PrefixFirst NameLast Name

Parent Email*

Parent Mobile*

Signature*

Authorisation Date:*

DayMonthYear