JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Website - Curledge Street Academy - Administration of Non - Prescribed Medicines in School
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name of Pupil
*
Your answer
Child's date of birth
MM
/
DD
/
YYYY
Class
*
N1- Penguins
N2 - Seals
RSA - Starfish
RCH - Seahorses
1KC - Dolphins
1CM - Cuttlefish
2TS - Kittiwakes
2EH - Guillemots
3SW - Jellyfish
3ED - Lobsters
4CH - Orcas
4LD - Turtles
5EH - Barracudas
5JM - Sharks
6JA - Sea Otters
6RU - Piranhas
Address
*
Your answer
Medical Condition
*
Your answer
Name of Medicine
*
Your answer
Dose
*
Your answer
Frequency of Dose (ie 4 times a day, every 2 hours)
*
Your answer
Time/Date of Last Dose
Your answer
Next Dose Due:
Time
:
AM
PM
Duration of Medication Course:
*
Your answer
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
No
Signed/Full Name (Parent/Carer)
By typing your name below you give your written consent to the above statement.
*
Your answer
Date
*
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Curledge Street Academy.
Report Abuse
Forms
