Burley & Woodhead CE Primary School Administration of Medicines in School Form

Please complete this online form to allow us to administer medicine to your child in school.
Child's Forename and Surname *
Child's Date of Birth *
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Child's Year Group *
Condition or Illness *
Name and Type of Medication (as described on container) *
For how long will your child take this medication? *
Date Medication Dispensed *
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Full directions for use and storage (as per instructions on container) include timings, dosage, special precautions and side effects *
Self Administration? *
Action to be taken if pupil refuses medicine *
Procedures to take in an emergency *
Parent/Carer Name *
Relationship to Pupil *
I understand that I must deliver the medication personally to the school office and I consent to authorised staff administering the above medication to my child. I accept that this is a service which the school is not obliged to undertake. I consent to medical information concerning my child’s health to be shared with other school staff and/or health professionals to the extent necessary to safeguard his/her health and welfare. I confirm that the medication has been prescribed by a doctor/consultant where necessary and that this information has been provided in consultation with my child’s doctor/consultant. If my child is asthmatic and has prescribed medication for the treatment of asthma, I consent to school administering their emergency salbutamol inhaler should this ever be required. *
Required
Date *
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