Request for school to administer medication

This form must be completed by parents/guardians

The school will not give your child medicine unless you complete and sign this form, and the Headteacher
has agreed that school staff can administer the medication.

Details of Pupil

Surname

Forename(s)

Address

Class/Form

Date of Birth

Sex

Male Female

Condition/Illness

Medication

Name/type of medication (as described on the container)

For how long will your child take this medication

Date dispensed

Full directions of use

Dosage and method

Timing

Special Precautions

Side Effects

Self Administration

Procedures to take in an Emergency

Contact Details

Name

Daytime Telephone No

Your email address

Relationship to Pupil

Address (if different to pupil)

Data Protection

I consent to providing this information to the Academy. It will be processed in accordance with the Trust Privacy Policy.