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St Monica's Catholic Primary School
Permission to Administer Medication at School
This form
must
be completed so that school staff can administer medication to your child during the school day.
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* Indicates required question
Email
*
Your email
Child's Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Class
*
Nursery
Reception
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Name of Medication
*
Your answer
Expiry date of Medication
*
Your answer
Type of Medication
*
Pump
Spray
Drops
Tablets
Liquid
How much Medication should be given?
(Dosage as described on the label)
Your answer
What time(s) of the day should the Medication be given?
*
Your answer
Are there any known side effects that the school should be aware of?
Your answer
Name of Parent
*
Your answer
Relationship to the child
*
Parent
Carer
Legal Guardian
Telephone Number
*
Your answer
The information contained in this document is t
o the best of my knowledge, accurate at the time of completing this document
I give consent for school staff to administer the above medication in accordance with the school's policy.
I will inform the school immediately, if there is any change in dosage or frequency of the medication.
*
Yes
No
Parent/Carer Name
*
Your answer
Today's Date
*
Your answer
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