Medication in Schools

This form must be completed by parents/carers.
If staff have any concerns discuss this request with healthcare professionals.

Details of Pupil

Surname:

Forename(s):

Address:

Date of Birth:

YYYY

Class:

Condition or illness:

Medication

Parents must ensure that in date properly labelled medication is supplied.

Name of Medicine:

Procedures to be taken in an emergency:

Contact Details

Name:

Phone Number - Mobile/Home:

Phone number - Work:

Relationship to child:

Website