Medicine Administration Form

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The school will not give your child medicine unless you complete this form.

Full name of your child *

Date of birth *

YYYY

Tutor group *

Medical condition or illness *

Medicine

This section is for details about your child's medication.

Name/type of medicine (as described on container) *

Expiry date *

YYYY

Dosage and method *

Time(s) of administration *

Are there any special precautions/other instructions the school needs to be made aware of?

Please list any side effects that the school needs to be made aware of

Is the medicine self-administered by your child?

Yes

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Please be aware that medicines must be in the original container dispensed by the pharmacy

Contact details

This section is for your contact details.

Your name *

Daytime telephone number (preferably a mobile number) *

Relationship to child (e.g. mother) *

Home address *

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to the school staff to administer medicine in accordance with the school policy. I will inform the school immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped. If you agree to the above, please write your name below.

Please write your name here if you agree to the above statement *

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