Woodland Grange Primary School
Request for Administration of Medicines

FROM: Parent/Guardian of________________________(full name of child)

DATE:___________________________________________________

My child has been diagnosed as suffering from:

_________________________________________________(name of illness)

He/She is considered fit for school but requires the prescribed medicine to be administered during school hours:

______________________________________________(name of medicine)

Could you please therefore administer:

_______________________________________________________(dosage)

at________________________________________________________(time)

with effect from____________________________________________ (date)

to*_______________________________________________________(date)

The medicine should be administered by mouth**/in the ear**/nasally**/other**

* Delete if long term medication.

** Delete as appropriate

I understand that all staff are acting voluntarily in administering medicines and have the right to refuse to administer medication. I understand that the school staff cannot undertake to monitor the use of inhalers carried by children, and that the school is not responsible for loss or damage to any medication.

I undertake to update the school with any changes in administration for routine or emergency medication and to maintain an indate supply of the medication.

Signed________________________________________________________

Name of Parent/Guardian {Please print)______________________________

Name of Child__________________________________________________

Contact Telephone No:        Home______________________________ Work____________________________________