Request for child to carry/administer their own medicine

Please use this form if your child is in Years 4-6 and they have medicine that they are able to self administer and/or a medicine they may need in an emergency such as an asthma inhaler or Epipen. It is the parent/carers responsibility to ensure emergency medicines are within date and that another supply of the medicine stored safely within the classroom in case of emergency and the child is unable to adminster the medicine themselves.

Non-prescription medicines may also be self-administered by children in years 4-6 only, but it is essential that these are handed to the class teacher so they may be stored safely. Only one dose of the medicine should be brought to school each day. Over the counter medicines that have not been prescribed cannot be adminstered by staff.

Request for child to carry his/her own medicine

 
This form must be completed by parents/guardian.
 
If staff have any concerns discuss this request with healthcare professionals.
 

Name of School
Bishops Down Primary School
Child’s name
 
Year
 
Date of birth
 
Name of medicine
 
How the medicine should be administered
 
Procedure to be taken in an emergency. Please continue overleaf if necessary.
 
 
 
Parent’s contact name
 
Day time telephone number
 
Relationship to child
 

 
Please indicate which of the following apply.
 
I would like my son/daughter to carry his/her medicine on them for use in an emergency or as necessary. Yes/No
 
I consent to my son/daughter administering their own medicine.  Yes/No
 
Signed……………………………………. Print name………………..
 
Date…………...................