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Parental Consent to Administer Medicine

This school/setting will not give your child medicine unless it is in accordance with our Supporting Pupils with Medical Conditions Policy and Procedures and you complete and sign this form. 


PLEASE NOTE: Medicines must be in the original containers as dispensed by the pharmacy.

2. Gender
Male
Female
3. Date of birth
Day
Month
Year
7. Medicine Date of Expiry
Day
Month
Year
12. Can the child self-administer?
Yes (go to question 13)
No (go to question 14)
13. If YES to question 12 is supervision required?
Yes
No
14. Does any medicine need to be carried by the child on their person, what and where will they keep it?
Yes
No
20. I understand that I must deliver the medicine personally to a member of the OMG Administration Staff
Yes
No
21. I understand that my child must have a working, in-date and sufficiently full inhaler, clearly labelled with their name, which they will bring with them every day.
Yes
No
Not applicable
22. I consent to my child receiving, in an asthma emergency, salbutamol which has not been prescribed to them
Yes
No
Not applicable
23. I understand that my child must have the number of working and in-date AAIs that their medical practitioner has recommended, clearly labelled with their name, which they will bring with them every day.
Yes
No
Not applicable
24. I consent to my child receiving, in an anaphylaxis emergency, adrenaline not prescribed to them
Yes
No

Declaration: The above information is, to the best of my knowledge, accurate at the time of writing and I consent to staff administering medicine in accordance with the Policy. I will inform the school/setting immediately, in writing, if there is any change in dosage or frequency of the medicine or if the medicine is stopped.

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