Section 1 Details of medication to be administered by school (Parent/Carer to complete) – Insert student photo below. Student name Date of Parent/carer name Contact number I hereby request that school staff administer the following medication to my child at school or during school activities, as specified in this section. Dosage Name of medication (e.g. oral) Time/s to be given during school (e.g. 1 tablet) Additional information Parent/carer signature Date Section 2 Record of administration of a single medication at school (School use only) – KEY: A Student absent; S Self administration; P Parent/carer administered medication; X School closed; O Off campus; N/S No supply of medicationContact parent/carer; – – – – – – R Student RefusedContact parent/carer – MONTH TIME 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb May June July
Section 1 – Details of medication to be administered by school (Parent/Carer to complete) Insert student photo below. Student name Date of Parent/carer name Contact number I hereby request that school staff administer the following medication to my child at school or during school activities, as specified in this section. Name of medication Dosage (e.g. 1 tablet) (e.g. oral) Time/s to be given during school Additional information Parent/carer signature Date Section 2 – Record of administration of a single medication at school (School use only) KEY: A – Student absent; S – Self administration; P – Parent/carer administered medication; X – School closed; O – Off campus; N/S – No supply of medicationContact parent/carer; R – Student RefusedContact parent/carer MONTH TIME 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb May June July
more-than-3-daily-doses-medication-form.docx