Medical Consent Form

The school will not give your child medicine unless you complete and sign this form.

Parental agreement for Rothwell School staff to administer medicine

Date for review to be initiated by

School Name:*NurseryInfant SchoolJunior School

Details of Pupil

Surname Forename(s): Date of Birth

Boy or GirlBoyGirl

Class Condition or illness:

Medication: Parents must ensure that in date, properly labelled medication is supplied.

Name/Type of Medication (as described on the container): Add a photo of the prescription box label (showing dosage and patient name)* No file chosen Date dispensed: Expiry date: Full Directions for use (Dosage and method) Timing/Frequency: Special precautions Are there any side effects that the School needs to know about

Can the child administer this medicine themselves?*YesNo

Procedures to take in an emergency

Note that medicines MUST be in the original container as dispensed by the pharmacy

Parent/Carer details and agreement

Parent Name Daytime Phone Number Your Email Address* Relationship to child Address I understand that I must deliver the medicine personally to (agreed staff member name):

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to the 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.*YesNo

Date