Administering medicine at ryburn

If your child needs to take medicine when they’re at school, please complete this form so we have your consent to administer it. We ask that all medicine is in it’s original container, and is brought in to school by a parent or carer.

Parental agreement for school to administer medicine

Name of School/Setting

Where will the medicine be administered?

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Form Group

Medical Condition or Illness

Name/Type of Medicine

As described on the container

Dosage and Method

as indicated on the prescription

Timing

When should this medicine be taken?

Medicine Expiry Date

YYYY

Special precautions/other instructions?

Are there any side-effects that we should be aware of?

Procedures to take in an emergency

Medicines must be in the original container as dispensed by the pharmacy

Self Administration

Yes

Name

Your contact details in case we need to check any details

First Name

Last Name

Daytime Telephone Number

Relationship to child

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I understand that I must personally delivery the medicine to school

Yes I will personally deliver any medicine to school

Signature

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

Parental agreement for school to administer medicine

EXECUTIVE HEADTEACHER: DAVE HEWITT

Head of school: DONNA WATKINS

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