Permission to administer medicine from home

Parental Agreement for Windlesham School to Administer Medicines - pre-planned

Please Note: Medicines must be in the original container as dispensed by the pharmacy.

The school will not give your child medicine unless you complete and sign this form. If more than one medicine is to be given , a separate form should be completed for each medicine.

Date of completion:

Child's Name:

Class Teacher / Tutor:

Name of Medicine (as found on packaging):

Expiry Date of Medicine:

Dosage to be given (Please state unit of measure as well e.g. 5ml)

When should this be given?

If given more than once when what other time should this be given?

Number of tablets / quantity of medicine given to school:

Any further information:

Parent Daytime Telephone Number:

medicine school: tablets

Name and Contact Number for GP:

Review Date If Needed:

The information above is, to the best of my knowledge, accurate at the time of writing and I give consent for Windlesham School staff administering medicine in accordance with the school policy. I will inform the school immediately, in writing, if there are any change in doseage or frequency of the medication or if the medication has stopped.

Signature of Parent/Carer:

Clear Signature

Print Name:

Today's Date: