Request to Administer Prescribed Medication Form

If you require school staff to administer a prescribed medication for your child's medical condition or illness, 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 *

Your mobile number *

Your relationship to the child *

Child's first name *

Child's surname *

Child's date of birth *

 

Child's Class *

Medical Condition or Illness *

Name of medication (as described on container) *

Please note that we will only administer prescribed medication. We advise parents to give doses of antibiotics outside of school hours where applicable.

Expiry Date *

It is the parent's responsibility to ensure that medication remains in date.

 

Dosage and method *

Time medicine is required if applicable

 

Other

Are there any side effects that the school needs to know about? *

Name of GP Surgery and contact phone number *

Procedure to take in an emergency *

The information provided is, to the best of my knowledge, accurate at the time of submission and I give consent to school staff administering medicine in accordance with the school policy. I will inform the school immediately, in writing, if there is any change in dosage or frequency of the medication, or if the medicine is stopped (Please type 'Yes' if you agree) *

Please provide a signature. *