Parental Agreement for School to Administer Medication

The school will not give your child medicine unless you complete this form, and the Headteacher has agreed that school staff can administer the medication.

Please note: Medicines must be in the original container as dispensed by the pharmacy, labelled, in-date and include instructions for administration, dosage and storage. School are only able to administer non-prescribed medicines to children if they are accompanied with a signed letter from the child’s GP.

Name of Child

First Name

Last Name

Date of Birth

YYYY

Class

Medical condition or illness

Name/type of medication

Expiry date on medication

YYYY

Dosage and method

Timing

Special precautions/other instructions

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

Self administration?

Yes

Procedures to take in an emergency

Name of parent

First Name

Last Name

Daytime telephone number

Relationship to child

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. Medication should be in date, labelled and in the original packaging, including instructions for administration, dosage and storage. I understand that I should supply and dispose of any medication that the school holds for my child.

Tick to confirm you have read the above statement