Pupil Medication Request

Where possible the need for medicines to be administered at school should be avoided. Parents are therefore requested to try to arrange the timing of doses to avoid lesson time and the subsequent impact on your child's learning. Please note, when medication is prescribed 3 times per day we will not be able to administer at school as this can be achieved outside school hours.

We will administer medicines to your child during their lunch break only. Only in exceptional circumstances will medicines be given outside these times and must be discussed with the office in advance.

Child's Name:* Class:* Parent's surname if different: Condition or illness:*

Please tick the appropriate box:*My child will be responsible for the self administration of medicines as directed belowI agree to members of staff administering medicines/providing treatment to my child as directed below

I agree to update information about the child's medical needs held by the school and that this information will be verified by GP and/or medical Consultant. I will ensure that the medicine held by the school has not exceeded its expiry date.

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:

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

Any special instructions/allergies: Please indicate any medication that your child has been given before coming to school today and the time it has been given. Where nothing has been given please also indicate this.* 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:*

FOR OFFICE USE ONLY

Parents/Carers of Early Years children
By signing below I acknowledge that the requested medication was administered to my child:

Parent Signature: Parent Name: Date:

Pupil Medication Request

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