We will not give your child medicine unless you complete and sign this form. School has a policy that the staff can administer medicine.
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Name of school/setting
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Name of child
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Date of birth
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Class
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Medical condition/illness
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Medicine
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Name or type of medicine (as described on the container)
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Date dispensed
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Expiry date
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Agreed to be initiated by (staff to sign)
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Dosage and method
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Timing
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Special precautions
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Are there any known side effects?
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Procedures taken in an emergency
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Contact details
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Name
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Daytime telephone number
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Relationship to child
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Address
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I understand that I must deliver the medicine personally to the class teacher of my child.
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(staff to sign)
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I accept that this is a service that
I understand that I must notify
Date____________________________
Signature(s) ____________________________