Agreement to Administer Medication

Please complete the form below in full, to enable school to administer medication to your child as directed. As per our policy, we are unable to administer over the counter medications, all medication MUST be prescribed by a GP and be in the original container as dispensed by the pharmacy.

Name of Child* Class* Date of Birth* Medication condition or illness to be treated* Name of Medication* Start Date* End Date* Dose to be administered* Time to be Administered* Procedure to take in an emergency* Parent/Carer Name* Contact Telephone Number* Relationship to Child* Alternative contact name/contact GP surgery and address*

By submitting this form, I understand that I must deliver/ collect the medication at the school office, where it will be stored as required.
I accept that this is a service that the school are not obliged to undertake. I understand that I must notify the school of any changes in writing. The above information is to the best of my knowledge, accurate at the time of writing and I give consent to the school administering medicine in accordance with school policy. I will notify the school immediately if there are any changes to dosage, frequency or if the medication is stopped.