Parent / Carer consent to administer prescribed medicine.

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If your child requires medicine to be administered within the school day please complete this form.

All prescribed medicines must be in the original container as dispensed by the pharmacy, with the child's name, the name of the medicine, the dose and the frequency of administration, the expiry date and the date of dispensing included on the pharmacy label.

A separate form is required for each medicine.

By completing this form you are:

Giving per mission for the Head Teacher / Senior staff member (or his/her nominee) to administer the OTC medicine to your son/daughter during the time he/she is at school. You will inform the school immediately, in writing, if there are any changes to dosage or frequency of the medication or if the medication is no longer needed.

You understand that it may be necessary for this medicine to be administered during educational visits and other out of school activities, as well as on the school premises.

You also agree that you are responsible for collecting any unused or out of date medicines and returning them to the pharmacy for disposal. If the medicine is still required it is your responsibility to obtain new stock for the school.

You are confirming that the information submitted is, to the best of your knowledge, accurate at the time of writing.

Email *

Child Name *

Class *

Childs date of birth *

Name of medicine *

Strength of medicine *

How much dose to be given For example: One tablet, 5ml spoonful *

At what time(s) the medication should be given *

Time

Reason for medication *

Duration of medicine Please specify how long your child needs to take the medication for *

Are there any possible side affects that the school needs to know about? If yes please list them. *

I give permission for my son/daughter to carry their own salbutamol asthma inhaler. *

Yes

Not applicable

I give permission for my son/daughter to carry their own adrenaline auto injector pen for anaphylaxis *

Yes

Not applicable

I give permission for my son/daughter to carry their own salbutamol asthma inhaler and use it themselves in accordance with the agreement of the school and medical staff. *

Yes

Not applicable

Contact details in case of an emergency *

Name of GP Practice and contact number *

A copy of your responses will be emailed to the address you provided.

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