Parental Request for the Administration of Medication during School Hours
Child’s Name: _________________________________________________________________________________
Class: ______________________________________ DOB: ____________________________________________
Home Address of Child: _________________________________________________________________________
Name and Address of GP: _______________________________________________________________________
_________________________________________ Tel No: _____________________________________________
I would like to request that my child be administered medication as detailed with effect
from_________________________________________ to _____________________________________________.
I agree to abide by the school’s policy on administering medication.
Parents Signature: _____________________________________________________________________________
Date: __________________________________________ Contact No: ___________________________________
List of Prescribed Medicines
Brand Name and type
of Medication
Strength
Dosage
Time between
Doses
Date to commence
Please provide the date _____________________ and time ________________________ of the last dosage given.
Any other instructions: __________________________________________________________________________
Staff Use Only
For the member of staff taking these instructions: Please check the following:
 Have all the sections above been completed
 Does the medication bottle/pack have a prescription label from a pharmacy/dispensing chemist
 Check that the medication is a recent prescription
 Check that the medication is in date – advise parent if this medication is close to its expiry date
 Note if there any specific storage instructions for the medication
If you are happy to administer/supervise this medication, please sign and date this form below
Staff member____________________________________________ Date __________________________