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: _____________________
Name/Type/Strength of Medication ______________________________________________________________
(as described on the container) __________________________________________________________________
Date dispensed:______________________________________________ Expiry date: ____________________________
Dose and frequency:_____________________________________________________________________
(include specific timesif required)
Duration of treatment:_____________________________________________________________________________
(e.g. as needed/3 days etc.)
Side effects: _________________________________________________________________________
Any other relevant information: ________________________________________________________________________