Parental Agreement to Administer Medicine

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The school will not give your child medicine unless you complete and sign this form, and the school has a policy that the staff can administer medicine.

Email *

Name of Child *

Date of Birth *

YYYY

Group/class/form

Medical condition or illness *

Medicine

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

Has your child taken this medicine previously, without any adverse side effects? *

Yes

Maybe

Expiry Date *

YYYY

Dosage and Method *

Timing *

Special precautions/other instructions

Are there any side effects that the school/setting needs to know about?

Self-administration *

Yes

Procedures to take in an emergency

NB: Medicines must be in the original container as dispensed by the pharmacy

Contact Details

Name *

Daytime telephone number *

Relationship to child *

Address *

I understand that I must deliver the medicine personally to the staff member at the front office.

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school staff administering 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.

Print Name to Consent *

Date *

YYYY

Submit

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