Administration of Medications

Pupil Name

Home Address:

Date of Birth:

YYYY

Gender:

Male

Female

Pupil Class:

Please describe condition and give details of pupil's individual symptoms:

Name and type of Medication, Date medication was dispensed, and date of expiry as described on labelled container.

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

Full directions for use

Dosage, time, and method of administration:

Special precautions / Possible side effects:

Procedures to take in an emergency:

Parent/Carer emergency contact details:

I agree that the medical information contained in this form may be shared with individuals involved with the care and education of my child.
Enter name of parent or carer completing form.

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