Consent form for the storage and administration of medicines in school

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Email *

Name of Pupil *

Pupil's date of birth *

Which Invicta site does your child attend? *

Blackheath

Deptford

Pupil's Year and Class *

I confirm that I have parental responsibility for the above child because I am their: *

Mother

Father

Person with Residence Order

Guardian with parental responsibility

Other:

Name of medicine *

Required dosage *

Time to be administered *

How is the medicine to be administered *

Orally

Cream/Ointment to skin (applied by the child/ supervised by the first aider)

Ear/Eye/ Nose Drops

Additional information to be given about the medicine:

Name of the person to be contacted during the day:

Telephone/ Mobile Number:

I hereby give consent for the above medicine to be given to the pupil and confirm that it may be administered by a member of staff/ first aider as indicated above.

Yes

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