Sharmans Cross Junior School is committed to safeguarding and promoting the welfare of children and young people and
expects all adults to share this commitment
APPENDIX 3
CONSENT TO ADMINISTER MEDICINES
The school staff will not give any medication unless this form is completed and signed.
Dear Headteacher
I request and authorise that my child:
Name:…………………………………………………
Date of Birth:………………………………..
Address:……………………………………………………..………………………………………………….
Contact number:………………………………………
Child’s Class:……………………………….
to be given the following medication/give themselves the following medication
Name of medicine:……………………………………
At (state time): …………………………….
Start date:……………………………………………..
Finish date:………………………………….
This medication has been prescribed for my child by:-
Name of GP:………………………………….whom you may contact for verification. I have confirmed that it is
necessary to give this medicine during the school day and that three doses of this medication have been
taken by my child with no adverse reactions.
The medication must be clearly labelled indicating the contents, dosage and child’s full name.
Signed:………………………………(Parent/Guardian) Date:……………………………..
Date
Time
Dose
Administered by
Child’s signature
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