Medicine Administration Agreement
The School cannot give your child any medicine unless you complete and sign this form
Name of child:    
Date of birth:          
Medical condition or illness:     IHP? Y / N
Name/type of medicine (as described on the container):    
Expiry date:          
Dosage and method:    
Special precautions/other instructions:    
Are there any side effects that we need to know about?:    
Self-administration allowed – y/n:   Yes (tick):   No (tick):  
Procedures to take in an emergency:    
NB: Medicines must be in the original container as dispensed by the pharmacy
Parent/Guardian/Carer Name:    
Daytime telephone no.    
Relationship to child:    
I understand that I must deliver the medicine personally to the Office:   Sign to acknowledge
The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school staff administering medicine in accordance with the above instructions.

I will inform the school immediately if there is any change in dosage or frequency of the medication or if the medicine is stopped.
Signature(s):       Date:  
Record of any changes to instructions:
Change   Date Time CPS Initial Patent Initial
This form is based on the DfE document “Supporting Pupils With Medical Conditions (Templates) (May 2014).