West Pennard Primary School Administering of Medicine to Pupils

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Please use this form to give permission to members of staff to administer medication whilst your child is at school or on an off-site visit. Please notify the Office by email also, to ensure they are aware of this form having been completed.

Name of Child *

Date of Birth *

YYYY

Class *

Year R

Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Name / Type of Medicine *

Dosage *

5ml

7.5ml

10ml

Other (please specify)

Date(s) to be Given *

Time to be Given *

Reason for Medication *

Side Effects we Should Know About? *

Parent/Carer Name *

Submit

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