A Request for a Pupil to Carry His/Her Medication

This form must be completed by parents/carers.

Details of Pupil

1. Forname(s):

2. Surname:

3. Address:

4. Date:

YYYY

5. Class:

6. Condition or illness:

Medication

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

7. Procedure to be taken in an emergency:

Contact Details

8. Name:

9. Phone number (home/work/mobile):

10. Relationship to child:

11. I would like my child to keep his/her medication on him/her for use as necessary:

Yes

12. Your Name:

13. Relationship to child:

Website