Medical Administration Form

Jesus said, I have come that you should have life, life in all its fullness. John, 10:10

The school will not give your child medicine unless you complete and sign this form.

Details of Pupil

Surname
Forename(s):
Address
Date of Birth
Boy or Girl
Boy
Girl
Class
Condition or illness:
Other medications taken by the child:
Allergies:

Medication: Parents must ensure that in date properly labelled medication is supplied.

Name/Type of Medication (as described on the container):
Add a photo of the prescription box label (showing dosage and patient name) *
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Date dispensed:
Expiry date:
Full Directions for use (Dosage and method)

NB Dosage can only be changed on a Doctor’s instructions

Timing:
Special precautions
Are there any side effects that the School needs to know about
I understand that I must deliver the medicine personally to (agreed staff member name):
I accept that this is a service, which the school is not obliged to undertake. I understand that I must notify the school of any changes in writing.
Yes
No
Parent Name
Date
Your Email Address *
Please upload a copy of your signature *
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Submit