Langford Village Community School - Parental Agreement for Setting to Administer Medicine

Parents Forms Medicine - Parental Agreement for Setting to Administer

Parental Agreement for Setting to Administer Medicine

Please read the following information and complete/submit the form below:

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

NB: Medicines must be in the original container as dispensed by the pharmacy. School can only administer short term medicines that are prescribed to be given four times a day.

Name of school/setting

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?

Procedures to take in an emergency

Contact Details

Your name

Relationship to the child

Contact telephone number

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