WELLESLEY PRIMARY SCHOOL

REQUEST TO ADMINISTER MEDICATION FORM

Parents/guardians are advised that, unless you complete and sign this form the school will not administer medication to your son/daughter/ward. The Headteacher and staff must still agree to administer medication as this is a purely voluntary act on their part.

DETAILS OF PUPIL

Surname________________________ Forename (s)______________________________

Class/Form______________________________

CONDITION OR ILLNESS
Type of Condition or Illness 	________________________________________________

Name & Type of Medication 	________________________________________________
(as described on container)

How long will your child require the medication__________________________________
(ongoing or specific time span)

FULL DIRECTIONS ON USE
Dosage & Method 		________________________________________________

Timing				________________________________________________

Special Precautions 		________________________________________________

I understand that I must personally deliver the medicine to Class Teacher and accept that this is a voluntary service provided by the school.  I agree to indemnify the Local Education Authority and its employees against any claim howsoever arising as a result of the Authority’s agreeing to administer drugs or other medication supplied by us to the Head of Wellesley Primary School to our son or daughter

Signature of Parent/Guardian _________________________ Date _____________