Parkside Primary School

Parental agreement for school to administer prescribed medicine (short term - under 7 days)

The school will not give your child their prescribed medicine unless you complete and sign this form, and the school has a policy that staff can administer medicine.

Date form completed

Name of child

Class

Date of birth

Medical diagnosis or condition

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

WHEN TO BE GIVEN (Dosage & time)

Any other instructions:

Expiry date of medication:

Medicines must be in the original container as dispensed by the pharmacy

Tick to confirm

Agree review date to be initiated by (name of member of staff to be filled in by school)

Special precautions:

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

Self-administration (Asthma only)

Yes

Procedures to take in an emergency

Name and telephone number of GP

Contact Name

Daytime telephone/mobile

Relationship to child

Address

Any other information?

I give consent for school staff to administer the above mentioned prescribed medication to my child. I understand that I must deliver the medicine personally to the classroom.

I agree

I accept that this is a service that the school is not obliged to undertake.

I agree

I understand that I must notify the school in writing of any changes in my child’s condition/medication.

I agree

YEAR 5 & 6 CHILDREN ONLY I give authorisation for my child to take their medication home with them. (MEDICINE FOR ALL OTHER CHILDREN MUST BE COLLECTED BY AN ADULT)

I agree

Type name as signature (parent/guardian)

Click to confirm this as electronic signature

I confirm this acts as my signature

Date of signature

If more than one prescribed medicine is to be given a separate form should be completed for each prescription.

I agree