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Medication Request Form
This is to be completed when giving permission for a child to be administered medication at school. A digital copy is available to download from the school website and hard copies can be found in the foyer outside the school office.
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Student Name
*
Your answer
Year Level
*
Your answer
Type of Medication
*
Your answer
Dosage (Amount)
*
Your answer
Frequency (How many times a day)
*
Your answer
I have provided the original medication container
*
Yes
No (Please fill in details in the next question if you select this answer)
Other:
Required
If you selected 'No' or 'Other' please explain the medication details provided.
Your answer
I give permission for the medication listed above to be given to my child at school.
*
Yes
Required
Parent/Guardian Name
*
Your answer
The School's Privacy Policy and Standard Collection Notice are available at
www.sbflemington.catholic.edu.au/policies
and provides more information on how the School handles personal information.
A copy of your responses will be emailed to the address you provided.
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