Parental Agreement for School to Administer Medicine
Heygarth Primary School will not give your child medicine unless you complete this form, in line with our policy allowing staff to administer medicine. Please note medicines MUST be in the original container as dispensed by the pharmacy showing information such as dosage. On completion of this form, medicines should be handed to the school office by the parent/carer, which will then be checked against this form.
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Email *
Full Name of Child *
Date of birth *
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Class *
Medical Condition or Illness *
Describe what constitutes an emergency for the child, and action taken if this occurs *
Name/type of medicine (as described on the container *
Date dispensed *
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Expiry date *
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Dosage and method *
When to be given *
Any other instructions *
Special precautions *
Are there any known side effects? *
Will this be self-administered *
Procedures to take in an emergency *
Emergency contact Name *
Best contact phone number *
Relationship to child *
Address including PostCode *
Name and Telephone of GP *
I accept that this is a service that Heygarth Primary School is not obliged to undertake. The above information is, to the best of my knowledge, accurate at the time of completion and I give consent to the school (or my child) administering medicine in accordance with the school policy. I understand that I must notify the school in writing of any change in dosage or frequency of medication, or if medication has stopped. *
Name of Parent/Carer completing this form *
Relationship to Child *
Date of form completion *
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