Request for school to administer medication

REQUEST FOR SCHOOL TO ADMINISTER MEDICATION

 

The school will not give your child medicine unless you complete and sign this form, and the Headteacher has agreed that school staff can administer the medicine.

 

Pupil details:

Pupil’s name:                                                                            Class:                               Date of birth:

Address:

MEDICATION – Parents must ensure that in date, properly labelled medication is supplied.

Condition or illness:

Name/type of medication (as described on container)

For how long will your child take this medicine:………………………………. Date dispensed: ……………….

Full directions for use: ………………………………………………………………………….

                                    …………………………………………………………………………..

                                    …………………………………………………………………………..

Dosage and method:     …………………………………………………………………………..  Timing:………………………………..

Special precautions:     …………………………………………………………………………..

                                    …………………………………………………………………………..

                                    …………………………………………………………………………..

Side effects:               …………………………………………………………………………..

                                    …………………………………………………………………………..

Procedures to take in an emergency:…………………………………………………..

                                    …………………………………………………………………………..

 

CONTACT DETAILS

Name:                                  …………………………………………………………………

Daytime telephone number: …………………………………………………………………

Relationship to pupil:           …………………………………………………………………

Address:                             ………………………………………………………………….

                                           ………………………………………………………………….

 

I understand that I must deliver the medicine to the School Office and accept that this is a service which the school is not obliged to undertake.

 

Signature ………………………………………………………………………………………….   Date …………………………..

 

Relationship to pupil: ……………………………………………………………………..

Leave a Reply

Your email address will not be published.