Request For Medicine To Be Administered In School

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Name of Child *

Year Group *

Your name *

Relationship to child *

Medical condition/illness *

How many days has the doctor advised that the named child should receive his/her medicine during school time *

Name of medicine *

Medicine type *

Tablet

Liquid Mixture

Inhaler

Cream

Capsule

Other

Dosage *

Number of doses required and at what time *

Does the medicine have any storage requirements? *

Any precuations, special arrangements or side effects *

Please print your name below to acknowledge that you understand that the Head Teacher and staff at All Souls Catholic Primary School cannot be held responsible for any problems which may arise from the administration of medicine when given in accordance to these instructions. *

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