Request to Administer Medication Form

If you require school staff to administer prescribed medication for your child's illness or medical condition, please complete this consent form.

Please also complete this form if there are any changes to your child's prescription.

We collect and process all personal data in line with our privacy notices which can be found on the policies page of our website.

Please complete all fields marked (*)

Your first name *

Your last name *

Your email *

Name of Child *

Date of Birth *

 

Class *

Medical Condition or Illness *

Name/type of medicine (as described on the container) *

Expiry Date

 

Dosage and Method *

Timing *

Special precautions/Other instructions

Are there any side effects that we need to know about?

Procedures to take in an emergency

Tick this box to confirm The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school/setting staff administering medicine in accordance with the school/setting policy. I will inform the school/setting immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped. *

Name of contact *

Relationship to child *

Daytime telephone number *

Tick this box to show that you understand that you must deliver this medication personally to the admin office. *

Please provide a signature. *

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