JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Medication Form
Parental agreement for medicine administration.
Golftyn After School Club needs your permission to give your child medicine, please complete and sign this form to allow medicine administration.
* Indicates required question
Email
*
Record my email address with my response
Child's name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Class
*
Your answer
Healthcare need
*
Your answer
Medication
*
Your answer
Date dispensed
*
MM
/
DD
/
YYYY
Expiry date
*
MM
/
DD
/
YYYY
Dosage and method
*
Your answer
Time to be taken
*
Your answer
Side effects Club need to be aware of
*
Your answer
Self administration
*
Yes
No
Procedure in case of an emergency
*
Your answer
Your full name and relation to child
*
Your answer
Daytime contact number
*
Your answer
Address
*
Your answer
Please tick where you agree
*
I understand that I must deliver the medicine personally to school
The club manager can discuss medicine storage with my child's teacher
I understand I must notify the manager of any changes in writing
Required
Date
*
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Hwb.
Report Abuse
Forms
