Long Term Prescription Medicines Form
If your child requires medication on a regular basis during the school day and you have already discussed this with the SENCo/FSW and/or you need to make a change to an existing prescription please use this form.
Parental Agreement for School to Administer Prescribed Medicine
The school will not give your child medicine unless you complete and sign this form, and the school has a policy that the staff can administer medicine.
If more than one medicine is needed then a separate form must be completed for each one. Please add any additional information on the reverse of the form.
| Name of school | Bishops Down Primary School |
| Name of child | |
| Date of birth | |
| Year/Class | |
| Medical condition or illness |
Medicine medicines must be in the original container as dispensed by the pharmacy
| Name and strength of medicine (as described on container) |
|
| Date dispensed | |
| Expiry date | |
| Number of tables/quantity given to the school | |
| Agreed review date to be initiated by Helen Lawton | |
| Dosage (eg ml/mg) and method (eg by mouth, topical, inhaled) | |
| Time/s to be given | |
| Special Precautions | |
| Potential Side effects | |
| Self Administration (Yes or No: please write in the box to the right) |
|
| Procedure to take in an emergency |
Contact Details
| Name and daytime phone no. of parent/adult contact | |
| Relationship to child | |
| Name and phone number of GP |
- The above information is, to the best of my knowledge, accurate at the time of writing and I give my consent to the school administering the medicine in accordance with the medicines policy. I will inform the school in writing is there is any change in dosage or frequency of the medicine or if it is stopped.
- I understand that I must deliver the medicine personally to the school office or school nurse.
- I accept that this is a service that the school is not obliged to undertake.
Date__________________________ Print Name_________________________