Parental agreement for setting to administer medicine The school will not give your child medicine unless you complete and sign this form, and the school has a policy that the staff can administer medicine. Date for review to be initiated by Name of school Saint Benedict Name of child Date of birth House/form Medical condition or illness Medicine Name/type of medicine (as described on the container) Expiry date Dosage and method Timing Special precautions/other instructions Are there any side effects that the school/setting needs to know about? Self-administration y/n – Procedures to take in an emergency NB: Medicines must be in the original container as Prescribed by their Doctor and dispensed by the Pharmacy with clear label of students details Contact Details Name Daytime telephone no. Relationship to child Address I understand that I must send the Miss Angela Jordan (School Nurse) medicine to The above information is, to the best of my knowledge, accurate at the time of writing 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. Signature(s) Date
Parental agreement for setting to administer medicine The school will not give your child medicine unless you complete and sign this form, and the school has a policy that the staff can administer medicine. Date for review to be initiated by Name of school Saint Benedict Name of child Date of birth House/form Medical condition or illness Medicine Name/type of medicine (as described on the container) Expiry date Dosage and method Timing Special precautions/other instructions Are there any side effects that the school/setting needs to know about? Self-administration – y/n Procedures to take in an emergency NB: Medicines must be in the original container as Prescribed by their Doctor and dispensed by the Pharmacy with clear label of students details Contact Details Name Daytime telephone no. Relationship to child Address I understand that I must send the medicine to Miss Angela Jordan (School Nurse) The above information is, to the best of my knowledge, accurate at the time of writing 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. Signature(s) Date