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Medicine Administration Form
The School will not give medicine to your child unless you complete this form and the Headteacher has agreed school staff can administer the medication. Please complete one form per medication.
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* Indicates required question
Pupil's name
*
Your answer
Pupil's class
*
Choose
Nursery Miss Morris Morning
Nursery Miss Morris Afternoon
Nursery Miss Carney Morning
Nursery Miss Carney Afternoon
RGB
RMH
RGR
1BP
1EC
1MH
2SH
2KRD
2RF
3BC
3NM
3RS
4DP
4CK
4MH
5JJ
5DW
5JB
6VC
6KW
6LH
Pupil's date of birth
*
MM
/
DD
/
YYYY
Medical condition and/or illness
*
Your answer
MEDICATION
Please give full details of all medication
Name of medication (as written on the container)
*
Your answer
How long will your child take this medication?
*
Your answer
Date medication dispensed?
*
MM
/
DD
/
YYYY
DIRECTIONS FOR ADMINISTRATION
Dosage & Method
*
Your answer
Time when medication needs to be given
*
Your answer
CONTACT DETAILS OF PARENT / GUARDIAN
Name of Parent / Guardian
*
Your answer
Contact telephone number
*
Your answer
Relationship to pupil
*
Your answer
I UNDERSTAND I MUST DELIVER THE MEDICINE PERSONALLY TO THE SCHOOL OFFICE AND ACCEPT THIS IS A SERVICE WHICH THE SCHOOL IS NOT OBLIGED TO MAKE. MEDICINE WILL ONLY BE RETURNED BY SCHOOL TO AN ADULT.
*
SIGNED:
Your answer
Date form completed
*
MM
/
DD
/
YYYY
Submit
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