Burley & Woodhead CE Primary School Administration of Medicines in School Form

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Please complete this online form to allow us to administer medicine to your child in school.

Child's Forename and Surname *

Child's Date of Birth *

YYYY

Child's Year Group *

Reception

Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Condition or Illness *

Name and Type of Medication (as described on container) *

For how long will your child take this medication? *

Date Medication Dispensed *

YYYY

Full directions for use and storage (as per instructions on container) include timings, dosage, special precautions and side effects *

Self Administration? *

Yes

Action to be taken if pupil refuses medicine *

Procedures to take in an emergency *

Parent/Carer Name *

Relationship to Pupil *

I understand that I must deliver the medication personally to the school office and I consent to authorised staff administering the above medication to my child. I accept that this is a service which the school is not obliged to undertake. I consent to medical information concerning my child’s health to be shared with other school staff and/or health professionals to the extent necessary to safeguard his/her health and welfare. I confirm that the medication has been prescribed by a doctor/consultant where necessary and that this information has been provided in consultation with my child’s doctor/consultant. If my child is asthmatic and has prescribed medication for the treatment of asthma, I consent to school administering their emergency salbutamol inhaler should this ever be required. *

I have read and understood the statement above and agree to the terms and conditions

Required

Date *

YYYY

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