Medication request form
Request for school to administer medication both in school and off-site during school visits/activities

The school will NOT give your child medication unless you complete this form. With the agreement of the Headteacher, some school staff have volunteered to administer medication.

Please note: This agreement could be withdrawn at any time.
Email *
Pupil name: *
Pupil Date of Birth: *
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Address and postcode: *
Condition/illness: *
Medication *
Name or type of medication as described on the container
For how long should your child take this medication?
Medication Start date: *
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DD
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YYYY
Medication End date: *
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DD
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YYYY
Full directions for use: *
Please include correct dosage and method of administration.
Time(s) to be given *
Procedures to be taken in an emergency: *
Parent/Carer Name: *
Parent/Carer daytime telephone number: *
I understand that I must arrange for the medicine to be delivered to the school into the safe keeping of the Healthcare assistant, Admin team or the Headteacher. I accept that this is a service that the school is not obliged to undertake. *
The medication must be in its original container, complete with the medication information leaflet.
Required
A copy of your responses will be emailed to the address you provided.
Submit
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