Request to Administer Prescribed Medication Form

Please complete all fields marked (*)

Your first name *

Your last name *

Your email *

Your mobile number *

Your relationship to the child *

Child's first name *

Child's surname *

Child's date of birth *

Child's Class *

Medical Condition or Illness *

Name of medication (as described on container) *

Please note that we will only administer prescribed medication. We advise parents to give doses of antibiotics outside of school hours where applicable.

Expiry Date *

It is the parent's responsibility to ensure that medication remains in date.

Dosage and method *

Time medicine is required *

Are there any side effects that the school needs to know about? *

Procedure to take in an emergency *

The information provided is, to the best of my knowledge, accurate at the time of submission and I give consent to school staff administering medicine 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 (Please type 'Yes' if you agree) *

Please provide a signature. *

Woodborough CofE Primary School

Woodborough Church of England Primary School

Request to Administer Prescribed Medication Form