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Consent Form - Child Medication Request
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* Indicates required question
Email
*
Your email
Child's Full Name
*
Your answer
Child's Class
*
Your answer
Parent's Name
*
Your answer
Emergency Contact 1 - Name and Telephone Number
*
Your answer
Emergency Contact 2 - Name and Telephone Number
*
Your answer
Nature of illness or condition
*
Your answer
Name of medication
*
Your answer
Dose and instruction for administration
*
Your answer
Frequency and times medication is required
*
Your answer
Completion date of course of medication (if known)
Your answer
Expiry date of medication
*
MM
/
DD
/
YYYY
I agree to members of staff administering medicines and providing treatment or care to my child as detailed above.
*
Yes
No
I agree to update information about my child's medical needs, held by the school, on a regular basis.
*
Yes
No
I will ensure that the medicine held by the school has not exceeded its expiry date.
*
Yes
No
Procedures to be taken in an emergency
*
Your answer
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