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

Details of Pupil

Date of Birth
Boy or Girl
Condition or illness:
Other medications taken by the child:

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

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.
Parent Name
Please upload a copy of your signature*
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Upcoming Events

28 Jun
Snowy Owl After School Scooter Club
Date Mon, 28-Jun-2021 3:30 pm - 4:30 pm
5 Jul
Snowy Owl After School Scooter Club
Mon, 05-Jul-2021 3:30 pm - 4:30 pm
23 Jul
School Closed for the Summer Holidays
Fri, 23-Jul-2021 10:00 am - Mon, 30-Aug-2021 11:00 am
9 Aug
Free Summer Holiday Club
Mon, 09-Aug-2021 9:00 am - Fri, 13-Aug-2021 2:30 pm

Contact the School

Wilbarston Church of England Primary School
School Lane,
Wilbarston, Market Harborough
Leicestershire LE16 8QN

Telephone: 01536 771252
Contact the School Office by Email

Send us a Message