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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 Helen Lawton 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_________________________

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