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Medicine Authority Form
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* Indicates required question
Email
*
Your email
Student's Name
*
Your answer
Year Level
*
Your answer
I request that my child be given the following medication:
*
Your answer
Time(s) when medicine is given
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Your answer
Medicine is to be stored:
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Your answer
Procedure for giving medicine
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Your answer
Condition for which medicine is given
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Your answer
Name of prescribing doctor
*
Your answer
I accept responsibility for:
the decision to give this medication to my child, and acknowledge that the school is in no way responsible for that decision, now or in the future
notifying the school about any changes in dosage, time, or procedures, by filling out a new Medicine Authority form
delivering the medication personally to school
ensuring that the medicine is not past its expiry
notifying the school in writing if medication is no longer provided.
I accept that the school:
may not have a trained medical officer to administer medications
cannot guarantee that medication will be given at a precise time or by the same person
will dispose of any uncollected medicine at the end of the year
Parent/guardian's name (writing your name acts as signature and consent)
*
Your answer
Send me a copy of my responses.
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