APPENDIX H 

REQUEST TO ADMINISTER MEDICINE

Llantarnam Community Primary School

Growing and Learning Together

 

PARENT/CARER CONSENT FOR SCHOOL TO ADMINISTER MEDICATION TO A PUPIL

  • Medication will not be administered to your child unless a permission form is completed and signed.

  • A separate form should be completed for each different medication.

  • A new form must be completed if any details change e.g. a different dosage.

  • Parents/carers will be informed when a child refuses their medication.

  • Prescribed medicine must be in the original container it was dispensed in.

  • Prescribed medicine can only be administered to the child named on the prescription label.

  • Always hand medications directly to a member of staff – do not leave medicines in your child’s bag.

 

I have read the above information and agree to follow the guidance.

The information recorded above is, to the best of my knowledge, accurate at the time of writing.

I understand that the school is not obliged to administer medication, and in some circumstances an appropriate adult may be required to come to school to give medicines.

I give permission for a member of staff to administer medicine to the child name above, in accordance with the information recorded above.

 

Name _______________________________________________            Relationship to child ________________________

 

Signature ____________________________________________________Date ____________________________

Name of child: _________________________________________________________     Date of birth: _____________________

Class/Teacher:________________________________________________

Condition/Illness:___________________________________________________

Name/Type/Strength of Medication ______________________________________________________________

(as described on the container) __________________________________________________________________

Date dispensed:______________________________________________ Expiry date: ____________________________

(if applicable)

Dose and frequency:_____________________________________________________________________

(include specific timesif required)

 

 

Duration of treatment:_____________________________________________________________________________

(e.g. as needed/3 days etc.)

Side effects: _________________________________________________________________________

(if applicable)

Any other relevant information: ________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

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