Medication Consent Form 22/23

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Parent to complete prescribed medicines to be brought into school

Email *

Name of Child *

Medical Need (Illness with child) *

Year Group *

Year EYFS

Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Class *

Name of medication and reason for taking *

We are permitted to give medicines once a day during school hours please indicate the time. For medicines to give 4 times daily we suggest - 8.00am, 12noon school, 3.30pm and then before bed. For 3 times a day we suggest Breakfast, after the school day and then bedtime. *

Only for pupils who attend after school club Explorers - permission to give an after school dosage on four times a day at 4pm. *

I agree

I do not want this

Not applicable my child does not attend after school club explorers.

Dosage *

Duration of course - number of days/weeks *

I will ensure the school has adequate supplies of this medication *

I agree

Required

A doctor or hospital have prescribed the medicine it is correctly labelled and dated in the original packaging. *

Yes

I give permission for a member of staff who has received appropriate training in accordance with the School Medical Policy and Local Authority code of practice *

Yes

Signed (Please write your name in full) - your email will be the evidence of your signature. *

Date *

YYYY

A copy of your responses will be emailed to the address you provided.

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