REQUEST FOR ADMINISTRATION OF MEDICINES

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Name of Child *

Class *

Date
*

YYYY

My child has been diagnosed as suffering from (name of illness).
*

He/She is considered fit for school but requires the following prescribed medicine to be administered during school hours (name of medicine).
*

Could you please therefore administer (dosage)

at (time). *

With effect from (start date) *

YYYY

to (end date). *

YYYY

The medicine should be administered by *

mouth

in the ear

nasally

Other:

I understand that all staff are acting voluntarily in administering medicines and have
the right to refuse to administer medication. I understand that the school cannot
undertake to monitor the use of inhalers carried by children, and that the school is
not responsible for loss or damage to any medication.

I undertake to update the school with any changes in administration for routine or
emergency medication and to maintain an in-date supply of the medication.

Name of parent/relative
*

Telephone
*

Email *

Signed (Parent/Carer with Parental responsibility)
*

Date
*

YYYY

Submit

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