Form 3

Parental Agreement For School To Administer Medicine

We will not give your child medicine unless you complete and sign this form and we have a policy that staff can administer medicine.

Our online forms make submitting essential documents and information quick and secure, saving you the hassle of paper forms. Let’s work together for a greener environment and enjoy the benefits of our digital enrolment process. However, if you need a paper copy, these are available from the schools main office.

Step 1 of 2

Name of the child's school(Required)

Child's Name(Required)

First Last

Date of birth (dd/mm/yyyy)(Required)

Class(Required)

Medical condition/illness(Required)

Medicine Information

Child's name who the medicine is prescribed to on the container(Required)

Name/type of medicine (as described on the container)(Required)

Date to commence medication (dd/mm/yyyy)(Required)

Date to cease medication (dd/mm/yyyy)(Required)

Dispensed date (dd/mm/yyyy)(Required)

Medicine expiry date (dd/mm/yyyy)(Required)

Agreed review date to be initiated by(Required)

Name a member of staff

Dosage and method(Required)

eg Oral, inhaled

Timing of dosage(Required)

Special precautions

Are there any side effects that the school needs to know about?(Required)

Self-administration(Required)

Yes

Procedures to take in an emergency(Required)

Contact Information

Name(Required)

First Last

Contact number(Required)

Relationship to the child(Required)

Address(Required)

Street Address Town/City Post Code

Consent

Name of the person filling out this form(Required)

First Last

54519