Long Term Medicine Record
Would you please complete this form below if you wish the school to administer medication to your child. If more than one medicine is to be given, a separate form should be completed for each.  The school will not give your child medicine unless you complete this form and the Headteacher has agreed that school staff can administer the medication.
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Email *
Details of Pupil:
Forename(s): *
Surname: *
Class: *
Address: *
Postcode: *
Gender? *
Date of Birth: *
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Condition or Illness: *
Medication Details:
Name/Type of Medication (as described on the container): *
For how long will your child take this medicine: *
Dosage and method: *
Date medication dispensed: *
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DD
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Timing (what time(s) should the medication be administered): *
Self-Administration? Can your child administer their medication by themselves once given to them by an adult, and not need adult support to take it? *
Side effects:
Special Precautions:
Procedures to take in an emergency:
Name of Parent/Carer: *
Contact Numbers (Home, Work, Mobile): *
Please indicate, by selecting the option below that you understand you must deliver the medicine personally to the school office and accept that this is a service which the school is not obliged to undertake. *
Date: *
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