Permission to Administer Prescribed or Pharmacy Medication

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By submitting this form I agree to the following:

I accept full responsibility for maintaining medication supplies, having my child’s name, the name of the drug and the correct dosage on the container and ensuring the supplies will not have passed the expiry date. Prescription drugs must have the pharmacy label with name, dose and date included. 
I have given permission for a member of the school staff to administer the medication according to my child’s needs as indicated above and I accept that this may not be the same staff member each time. I also accept that the school will take due care with the administration of this medication but I release the school and the school’s staff from any responsibility associated with it. Likewise I understand that the school cannot be held responsible for any injury or fatality if correct procedures and systems have been followed. 

Child's Name:
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Date of Birth:
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Room Number:
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Parent/Caregiver name:
*

Parent/Caregiver phone number:
*

My child requires the following medication at school:
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The medication needs to be taken (time/indication)
*

My child requires:
*

Assistance to medicate

Can administer themselves

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