Pupil Medication Request

We will only administer medicines to your child where it cannot be given at home. When medication is needed 3 times a day we will not administer a dose as all 3 doses can be achieved at home. We will administer medications as close as possible to the requested time.

If submitted online a copy of this form will be sent to your supplied email address for your records.

Child name & class:* Contact number should we need to discuss this medication with you:*

Please tick the box if you agree to:members of staff administering medicines/providing treatment to your child as directed below or in the case of an emergency, as staff consider necessary.

Please tick the box if you agree to:my child will be responsible for the self administration of inhaler medication as directed below

Reason for medication e.g. sore throat, asthma etc.*

SCHEDULE OF MEDICATION:
Please record below the medication you wish your child to receive while at school.
Please note that if no completion date is recorded medicine will only be given to your child on the first day the form is submitted to the school office.

I wish for my child to receive the following medication and I will ensure that the medicine held by the school has not exceeded its expiry date

	Name of medicine	Dosage	Time of day required	Completion date of course	OFFICE USE ONLY: administered by (initials)
Medicine 1
Medicine 2
Medicine 3

Any special Instructions/allergies: I hereby confirm all information provided on this form is accurate. Please sign or type your full name as parent or carer:* Date of request:* Contact email:*

Pupil Medication Request

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