Request for student medication administration assistance

This form is to be completed by the parent or guardian and provides authorisation for the College to take any necessary actions with regard to the administration of medication for the student named below:
Student Name*

First NameLast Name
Student Date of Birth*

DayMonthYear
Type of medication required to be taken*

PrescribedNon-PrescribedPrescribed EpiPenPrescribed Ventolin
Name of Prescribed Medication?*
Name of Non-prescribed Medication?*
What is the required dosage?*
e.g. 1 x tablet, 10 ml etc.
How often should the medication be taken whilst at College?*

Once per dayTwice per dayThree per dayOnly as required
Requested Time 1

:HourMinutesAM/PM Option
Requested Time 2

:HourMinutesAM/PM Option
Requested Time 3

:HourMinutesAM/PM Option
Medication Route*

OralNasalTopicalInjectedOther
Details / Instructions*
Reason for Medication*
Known Side Effects
Epipen Treatment

To be administered only after a known exposure or a suspected exposure where symptoms occur. Please be sure to attach the Medical Action Plan at the bottom of this page which must be in date and reviewed yearly.
Anaphylactic or allergic reaction may be the result of the student being exposed to: *
What are the known symptoms of an exposure?*
What is the expected severity of a reaction?*

MildModerateSevereLife Threatening
Expiry Date of EpiPen

DayMonthYear
Date
Ventolin Treatment

To be administered when symptoms occur or as per a provided Asthma Management Plan. Please be sure to attach the Medical Action Plan at the bottom of this page which must be in date and reviewed yearly.
Asthmatic reaction may be a result of the student being exposed to: *
What are the known symptoms of the condition?*
What is the expected severity of the condition when presented?*

MildModerateSevereLife Threatening
Parent / Guardian Name*

First NameLast Name
Email*
example@example.com
Mobile Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctors Name*

First NameLast Name
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Number*
I {ParentName} request that my child {studentName} ;
Select which applies*

take (supervised self-administered) or be given the above medication as detailed above at the first aid office as per the prescribed schedule.due to the severity of the condition, carry their prescribed life saving medication on their person and self administer without seeking staff supervision as may be required. (Such as Epipen or Asthma inhaler.)
I {ParentName} accept and agree to observe the conditions imposed by the College and with understanding, agree that it is my responsibility to inform the College of any changes involving the administration of my childs medication.

I will provide the medication in its original packaging, including any instructional labels or materials supplied by the pharmacist and give permission to the Principal or delegated authority to obtain relevant information from the prescribing practitioner when necessary.

I understand that students are not permitted to carry on their persons any form of medication unless the prescribing medical practitioner has documented this requirement on the Medical Action Plan provided.
Please upload a copy of the Medical Action Plan as provided by the Medical Practitioner.

Browse Files

Cancelof
Signature*
Date*

DayMonthYear
Date
Should be Empty:

Epipen Treatment

Ventolin Treatment