Form from: Alwoodley Primary

In order for your child to receive medication in school it is necessary for you to complete the consent form below.

Leeds City Council or its agents will not be held liable for any injury or death arising form or out of the administration of the prescribed medication by appointed staff members other than through the Council's negligence.


Office Admin

Name of Child

Year Group

Class

Medical Condition

Medical Condition

Name of Medicine

Expiry Date

Dose prescribed

Time medicine to be given

Last date medicine to be given

Any other instructions

Would you like to add a another medicine

2. Name of medicine.

2. Expiry date

2. Dosage

2. Last date medicine to be given

Parental Details

Name of person completing this form

Contact number

Medical Centre

If other please state

The above information is, to the best of my knowledge, accurate at the time of completion and I give consent to school/setting staff administering medicine in accordance with the school policy. I will email the school immediately if there is any change in dosage or frequency or if the medication is stopped. (Please email [email protected]).  

Please sign below

signatureplease use your mouse or finger sign above

Please record date and time dose administered

Your name

Your email