Form from: St Michael and All Angels

Dear Parent/Carer

If your child needs to have medicine at school please complete the following to give your consent.  Medicines must be labelled with the child's name, be in the original container as dispensed by the pharmacy and should be handed into a member of staff.  Medicine cannot be administered to your child until this completed form has been received.

Paper copies of all our documents are available free of charge, please enquire at the school office.

Child's Details

Name of child

Date of birth


Medical condition or illness


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

Is this medication a CONTROLLED substance?

Expiry date

Dosage and method


Special precautions/other instructions

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

Can the child self administer?

Procedures to taken in an emergency

Details of parent/carer completing this form


Daytime telephone number

Relationship to child


I understand that I must deliver and collect the medicine personally to the school office or a member of staff.  The information I have given is to the best of my knowledge, accurate at the time of completing and I give consent to school to administering medicine in accordance with St Michaels policy for Supporting Children with Medical Conditions.  I will inform the school immediately if there is any change in dosage or frequency of the medication or if the medicine is stopped.

Please sign below

signatureplease use your mouse or finger sign above

Member of staff administering:- Please note below the date, time, dose and your initials EACH time this medicine is given.