Permission for Medicine at School

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Please fill in this form if your child requires medicine during school hours.
The school can only administer medicine that has been prescribed by a doctor.
If there are any changes in the medicines or the amount to be given please tell us immediately.

Name of child *

Class *

Name of medicine *

as shown on medicine container, or on prescription.

Dose to be given *

Please note where necessary if doses are different at different times

Please tick all that apply *

Yes

My child needs help to take the medicine

Medicine needs to be stored in the fridge

This is a long term medication which will need to be given to my child in school until I instruct otherwise

This is a short term medication which needs to be given to my child for the below specified period

Start date of medication *

YYYY

Days the medication should be administered *

Monday

Tuesday

Wednesday

Thursday

Friday

As and when required (child can request)

As and when required (parent should be contacted before administering)

Other:

Required

End date of medication (if required)

YYYY

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