Consent for school to administer medicine

Parental agreement for school to administer medicine

Staff will not give your child medicine unless you complete and sign this form.

Name of child* Class* Date of birth*

Medicines must be in the original container as dispensed by the pharmacy.

Medical condition or illness* Name of medicine* Date dispensed* Expiry date* Dosage* When to be given* Special precautions* Are there any side effects that the school needs to know about?

Can the child administer the medication them self?*YesNo

Procedures to take in an emergency* Parent/guardian name* Daytime telephone no,* Relationship to child*

I understand that I must deliver the medicine personally to the school office.*Yes

I understand that medication must be collected from the office each day by an adult if required (e.g antibiotics)*Yes

I accept that this is a service that the school is not obliged to undertake.*Yes

I understand that I must notify the school of any changes in writing.*Yes

Parent/guardian signature* Date*

Office use only:

Office personnel to check that the above meets the requirement of the prescription given by the GP. Staff will not administer any medication outside of a Doctor’s prescribed dose.

Admin name (1) Signature Date Admin name (2) Signature Date Headteacher signature Date