Medication request form

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Request for school to administer medication both in school and off-site during school visits/activities

The school will NOT give your child medication unless you complete this form. With the agreement of the Headteacher, some school staff have volunteered to administer medication.

Please note: This agreement could be withdrawn at any time.

Email *

Pupil name: *

Pupil Date of Birth: *

YYYY

Address and postcode: *

Condition/illness: *

Medication *

Name or type of medication as described on the container

For how long should your child take this medication?

Medication Start date: *

YYYY

Medication End date: *

YYYY

Full directions for use: *

Please include correct dosage and method of administration.

Time(s) to be given *

Procedures to be taken in an emergency: *

Parent/Carer Name: *

Parent/Carer daytime telephone number: *

I understand that I must arrange for the medicine to be delivered to the school into the safe keeping of the Healthcare assistant, Admin team or the Headteacher. I accept that this is a service that the school is not obliged to undertake. *

The medication must be in its original container, complete with the medication information leaflet.

I accept these terms.

Required

A copy of your responses will be emailed to the address you provided.

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