Medication Consent Form

Please complete all fields marked (*)

Your first name *

Your last name *

Date *

Name of pupil *

Date of Birth *

Year Group *

Medical Condition or illness *

Name/Type of medicine (as described on the container) *

Dosage and method *

Timing *

Are there any side effects that the schools/setting needs to know about? *

Expiry date / Last day taken in school *

Self-administration - Yes/No *

Yes

Any special precautions e.g. stored in fridge *

I confirm that this medicine will be delivered personally to the school office whenever possible. *

Yes

N / A

I will drop off and collect the medicine on a daily basis *

Yes

N/A

I will leave the medicine in school until the end of the course *

Yes

N / A

Before/After School Club - If my child attends KPK, I confirm that I have filled out the medical consent form via the app or printed, giving consent. Any medication should be handed to KPK staff. *

Yes

N / A

Bus/Taxi - If my child comes to school via bus or taxi, I confirm that I have filled in a medical consent form online via to app prior to your child coming to school.

Yes

I will ensure that any prescribed medicine is supplied to the school in a container clearly labelled (by the Pharmacist) with the name of the medicine, full instructions for use and the name of the pupil *

Yes

N / A

I will ensure that all medicines should be in the original container bearing the manufacturer's instructions for administration, dosage, and storage (the school may refuse to administer any medicines supplied in inappropriate containers). *

Yes

N / A

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school/setting staff administering medicine in accordance with the school/setting policy. I will inform the school/setting immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.

Please provide a signature. *

Knightlow CofE Primary School

Consent for the administration of medication in school