Request for School to Administer Medication

Details of Pupil

1. Forname(s)

2. Surname:

3. Address:

4. Date of Birth:

YYYY

5. Gender:

Female

Male

6. Class:

7. Condition or Illness:

Medication

Parents must ensure that in date, properly labelled medication is supplied.

8. Date dispensed:

YYYY

9. Expiry Date:

YYYY

Full directions for use:

10. Dosage and method:

NB Dosage can only be changed on a Doctor's instructions:

11. Timing:

12. Special Precautions:

13. Are there any side effects that the school needs to know about?

14. Self Administration?

Yes

15. Procedures to take in an emergency:

Contact Details:

16. Name:

17. Phone number (home/mobile):

18. Phone Number (work):

19. Relationship to pupil:

20. Address:

21. I understand that I must deliver the medicine personally to the agreed member of staff and accept that this is a service, which the school is not obliged to undertake. I understand that I must notify the school of any changes in writing.
Agreed member of staff:

22. Your Name:

Website