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Request to administer prescription medication
- Use this form to instruct us to administer prescription medication for your child.
- Where possible, medication should be administered at home.
- We will only administer medication that has been prescribed to your child.
- Medication must be presented in a labelled container clearly showing your child's name.
- Primary children will be collected and have their medication administered in the front office medical room.
- Secondary children will take responsibility to bring themselves to front office to have their medication administered.
Email address *
Your name *
Your answer
Your contact number *
Your answer
Relationship to child *
Child first name *
Your answer
Child surname *
Your answer
Form *
Your answer
Brief description of condition being treated with this medication *
Your answer
Medication type eg tablets, medicine, cream *
Name of medication *
Your answer
Can your child give him/herself this medicine with supervision? *
First dose date (in school) *
MM
/
DD
/
YYYY
Last does date (in school) *
MM
/
DD
/
YYYY
Dose requirement *
Dose quantity eg 1xtablet, 1x5ml, 1xpuff *
Your answer
Dose 1 time *
Your answer
Dose 2 time
Time
:
Dose 3 time
Time
:
This information is accurate to the best of my knowledge at the time of completing this form. I give consent to the school to administer the medication in accordance with Reach Academy Feltham policy. I will inform the school in writing of any changes to the above information. I understand it may be necessary to meet with a member of senior staff to discuss this request prior to medication being administered to my child (if you disagree with this statement we will not be able to administer medication to your child). *
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