Medicine Consent Form

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If your child is well enough to attend school but has been prescribed medicine to be taken during school hours then please complete the following form to give school staff permission to administer it.

Once you have completed this form, please email the office to let them know.

Name of child *

Date of Birth *

YYYY

Child's Class *

Foundation Stage

Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Medical Condition *

Name of medicine to be administered *

Dose of medicine to be given *

Time dose is to be given *

Time of last dose given at home? *

Time

Date to start administering medicine *

YYYY

Date of last dose *

The medicine should be taken by... *

mouth

nose

ear

other - please give details below

INHALERS - I give permission for my child to self administer their inhaler *

Yes

Non Applicable

Required

Tick each statement to confirm the following: *

I will update the school with any change in medication use or doseage

I will ensure the medication provided is in date

School is not responsible for any loss/damage to any medication

School will keep a record of medicine given and will inform parents if there has been any variation

Staff will be acting in the best interest of my child whilst administering medication

My child has taken this medicine or at least two doses of this medicine before and has not suffered any adverse reactions.

Required

Name of parent/carer completing this form *

Date form was completed *

YYYY

Any other comments

Submit

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