Parental Medical Agreement

Form from: Fryent Primary School

The school has a policy for administering medicine to children which has been prescribed by a medical professional and will not give your child medicine unless you complete and sign this form.

Medicines must be in the original container as dispensed by the pharmacy with the child's name clearly printed. Once this form has been filled in, you may bring the medication into school, clearly labelled with the child's name and leave it with the front office. The child must not keep it in their schoolbag.

Name of child:

Date of birth:

Child's class:

Medical condition/illness:

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

Dosage and Timing:

If your child normally has an inhaler at school and it is an emergency, do you give permission for your child to use the school's emergency inhaler?

Yes No

Is your child capable of self-administering their medication under the supervision of a member of staff?

Yes No

Procedures to take in an emergency:

Contact Details of a Parent/Carer

Parent/Carer's Name:

Telephone Number:

Please sign below

signature _{please use your mouse or finger sign above}