Instruction & Authorisation for the Administration of Medicine in School

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Please complete and submit when medication is sent to school with your child.

Authorisation

By submitting this form I hereby authorise the Head Teacher or person authorised by the Head Teacher to administer the medication detailed below. If any changes in the medication are prescribed I will notify the Head Teacher immediately.

I understand that the person who administers the medication will not be medically trained and that it is not part of their obligations under their contract of employment.

I confirm that I will be responsible for the provision of the medication, whenever required, in an appropriate container bearing a clear label showing -

The name of the medication
The name of the patient
The dosage
Specific directions for administration
Related precautions
The name of the dispensing pharmacy/doctor
The date of issue or the expiry date.

I confirm that I will be responsible for ensuring the medication has not expired.

I understand that the Head Teacher and school staff will take such care as would a reasonable prudent parent and I confirm that I will not hold the Governors, school staff or Education Authority responsible for any loss, damage or injury resulting from the administration of this medicine.

Email *

Child's First and Last Name *

Child's Class *

Robins

Swallows

Kingfishers

Owls

Eagles

Child's Date of Birth *

YYYY

Your First and Last Name *

Your Relationship to the Child *

Name of Medication *

Type of Medication *

Medicine

Tablets

Inhaler

Epipen

Cream

Other (Please give further details to the member of staff you hand the medication to)

Dose Required

Number of millilitres/tablets etc

Time to be Administered *

Possible Side Effects

Is this a long term medication? *

Yes

Does medicine need to be returned home each day? *

Yes

What date will the treatment finish, if applicable?

YYYY

Any other comments

Please use this space to provide any further information which you feel necessary.

A copy of your responses will be emailed to the address you provided.

Submit

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