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Temporary Administration of Medication

Please note that this form relates to temporary administration of medication. Any child requiring ongoing medication requires a personal medical care plan which will be discussed and agreed with the School Nurse and signed by both parties

Name of Pupil *

Class *

Teacher *

I request permission for my son/daughter to be given the following medication during school hours by the class teacher or designated member of staff.

Medication (ALL PRESCRIBED MEDICATION MUST BE IN THE ORIGINAL CONTAINER, AS DISPENSED BY THE PHARMACY WITH CLEAR INSTRUCTIONS ON HOW MUCH TO GIVE.) *

Dosage *

When to be taken *

How Long For? *

NB: ALL PRESCRIBED MEDICATION MUST BE IN THE ORIGINAL CONTAINER, AS DISPENSED BY THE PHARMACY WITH CLEAR INSTRUCTIONS ON HOW MUCH TO GIVE. Please hand the medication to the school nurse or the front of house.

Signature of Parent or Guardian *

Clear Signature

Date *

Temporary Administration of Medication

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