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The Echelford Primary School

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.

Please tick the box if you agree to:
Please tick the box if you agree to:

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.

 Name of medicineDosageTime of day requiredCompletion date of courseOFFICE USE ONLY: administered by (initials)
Medicine 1
Medicine 2
Medicine 3
The Echelford Primary School