Website - Curledge Street Academy - Administration of Prescribed Medicines in School
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Email *
Name of Pupil *
Child's date of birth *
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Class *
Address *
Medical Condition *
Name of Prescribing Doctors Surgery *
Name of Medicine *
Dose *
Frequency of Dose (ie 4 times a day, every 2 hours) *
Time/Date of Last Dose
Next Dose Due:
Time
:
Duration of Medication Course: *
I confirm that the above medicine has been prescribed by a doctor and I give permission for the Head Teacher (or his/her nominee) to administer the above named medicine during the time he/she is in school *
Signed/Full Name      (Parent/Carer)
By typing your name below you give your written consent to the above statement.
 *
Date *
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Year 4- 6  ASTHMA ONLY - I give my permission for my child to carry his/her asthma inhaler with them whilst at school and manage its use
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ASTHMA ONLY - Consent For Use Of The Emergency Salbutamol Inhaler, In the event of my child displaying symptoms of asthma, and their inhaler is not available or is unusable, I consent for my child to receive salbutamol from an emergency inhaler held by the school for such emergencies.
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Signed/Full Name (Parent/Carer)
By typing your name below you give your written consent to the above statement.
Date
MM
/
DD
/
YYYY
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