IRON ACTON CEVC PRIMARY SCHOOL

REQUEST TO ADMINISTER MEDICATION FORM

Parents/guardians are advised that, unless you complete and sign this form the school will not administer medication to your son/daughter/ward. The Headteacher and staff must still agree to administer medication as this is a purely voluntary act on their part.

DETAILS OF PUPIL

Surname________________________

Forename(s)______________________________

Home Address_________________________________________________________ _______________________________________________________________ _______

Date of Birth______________________ Class/Form________________________

CONDITION OR ILLNESS

Type of Condition or Illness _________________________________________________

Name & Type of Medication_________________________________________________

How long will your child require the medication_______________________________________________________ ____(ongoing or specific time span)

FULL DIRECTIONS ON USE

Dosage & Method ________________________________________________________

Timing___________________________________________________

Special Precautions_______________________________________________

CONTACT DETAILS

Name of Parent/Guardian__________________________________________________

Address_________________________________________________________

Daytime Telephone Number   ______________________________________________

Alternative Telephone Number ______________________________________________

I understand that I must personally deliver the medicine to Head/Secretary/Class Teacher and accept that this is a voluntary service provided by the school.

Signature of Parent/Guardian _________________________ Date _____________