Curledge Street Academy - Administration of Prescribed Medicines in School

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Email *

Name of Pupil *

Class *

Address *

Medical Condition *

Name of Prescribing Doctors Surgery *

Name of Medicine *

Dose *

Frequency of Dose *

Time of last dose

Date of last dose

YYYY

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 *

Yes

Signed/Full Name (Parent/Carer) *

Date *

YYYY

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

Yes

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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.

Yes

Clear selection

Signed/Full Name (Parent/Carer)

Date

YYYY

FOR OFFICE STAFF ONLY: Medicine Checked & Authorised by:

FOR OFFICE STAFF ONLY: Date

FOR TEACHING STAFF ONLY: Received by:

Submit

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