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Administration of Non-Prescribed Medicines in School
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* Indicates required question
Email
*
Your email
Name of Pupil
*
Your answer
Class
*
Your answer
Address
*
Your answer
Medical Condition
*
Your answer
Name of Medicine
*
Your answer
Dose
*
Your answer
Frequency of Dose
*
Your answer
Time/Date of last dose
Your answer
I give permission for the Head Teacher (or his/her nominee) to administer the above named medicine during the time he/she is in school.
*
Yes
No
Signed/Full Name (Parent/Carer)
*
Your answer
Date
*
MM
/
DD
/
YYYY
FOR OFFICE STAFF ONLY: Medicine Checked & Authorised by:
Your answer
Date
MM
/
DD
/
YYYY
FOR TEACHING STAFF ONLY: Received by:
Your answer
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