Parental agreement to administer medicine

The school/setting will not give your child medicine unless you complete and sign this form, and the school or setting has a policy that the staff can administer medicine.

Name of child* Date of birth* Class Medical condition or illness*

Medicine

Name/type of medicine (as described on the container)* Expiry date* Dosage and method* Timing* Special precautions/other instructions Are there any side effects that the school/setting needs to know about? Self-administration – y/n* Procedures to take in an emergency

NB: Medicines must be in the original container as dispensed by the pharmacy

Parent/Carer Contact Details

Name* Daytime telephone no.* Relationship to child* Address*

I understand that I must deliver the medicine personally to Mrs Lea or Mrs Cook.

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

Signature* Date* Please enter