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Administering Medication in School
Parental Agreement Consent Form
The school will not give your child medication unless you complete and submit this form
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* Indicates required question
Email
*
Your email
Student's Full Name
*
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Year Group and Tutor Group
*
Your answer
Medical Condition / Illness
*
Your answer
Name of Medicine (as described on container)
*
Your answer
Expiry Date
MM
/
DD
/
YYYY
Dosage, Method and Timing
*
Please outline how the medication is to be administered and when
Your answer
Special Precautions / Other Instructions / Any side effects that the school needs to know about
Your answer
Procedures to take in an emergency
Your answer
Name of Parent/Carer
*
Your answer
Parent/Carer Daytime Telephone Number
*
Your answer
NOTE: ALL MEDICATION MUST BE IN THE ORIGINAL CONTAINER AS DISPENSED BY THE PHARMACY
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