Form from: Florendine Primary School

School staff will not give your child medication unless this form is completed and signed. 


Dear Headteacher,

I request and authorise that my child (please select the correct statement below) the following medication.

Pupil Name

Class

DOB

Medical Condition or illness, and reason for medication

Name of Medication (NB MEDICINES MUST BE IN THEIR ORIGINAL CONTAINER AND CLEARLY LABELLED WITH A SPOON IF NECESSARY

Special Precautions e.g. after food

Any known side effects that school need to know

Dose

Time of Dose

Maximum Dose (if applicable)

Start Date

End Date

I confirm that:

I have received medical advice stating that it is, or may be in an emergency, necessary to give this medication to my child during the school day and during off-site school activities;

  • I agree to collect it at the end of the day/week/half term (delete as appropriate) and replace any expired medication as soon as possible, disposing of any unused medication at the pharmacy;
  • This medicine has been given without adverse effect in the past/ I have made the school aware any side effects that my child is likely to experience, and how the school should act if these occur (delete as appropriate);
  • The medication is in the original container labelled with the contents, dosage, child’s full name and is within its expiry date; and

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school staff administering medicine in accordance with the school policy and my child’s Care Plan. I will inform the school immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.

Parent Name

Please sign below

signatureplease use your mouse or finger sign above

Date completed

SCHOOL USE ONLY

Pupil Name

Class

Class Teacher/TA aware

Your name