BARNSLEY METROPOLITAN BOROUGH COUNCIL – EDUCATION SERVICES

This form is to be used for parental requests to school for the administration of a prescribed medicine.

SECTION 1

SCHOOL        ………………………………………………………………………………………………..

 

DATE OF REQUEST ……………………………………………………………………………………….

 

SECTION 2

PUPIL’S NAME ……………………………………………………………………………………………

YEAR GROUP ……………………………………………………………………………………………..

ADDRESS       ………………………………………………………………………………………………

                        ………………………………………………………………………………………………

                        ……………………………………………………………………………………………….

TELEPHONE NUMBER …………………………………………………………………………………...

DAYTIME EMERGENCY
CONTACT NUMBER ………………………………………………………………………………………

PARENT(S) OR
CARER(s) NAME      ……………………………………………………………………………………….

 

SECTION 3

NAME OF MEDICATION     ………………………………………………………………………………

CONDITION OR ILLNESS
eg. Ear infection                        ……………………………………………………………………………….

ISSUING PHARMACY          ………………………………………………………………………………..

DATE PRESCRIBED              ………………………………………………………………………………..

DETAILS OF DOSAGE         ………………………………………………………………………………..

DATE COURSE OF MEDICATION FINISHES ………………………………………………………….

 


 

SECTION 4

Name of GP     ………………………………………………………………………………………………..

Address           ………………………………………………………………………………………………..

           
Telephone No………………………………………………………………………………………………...

 

SECTION 5

Arrangements agreed with the parent(s) or carer(s) if child refuses to take medication.

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

SECTION 6  DECLARATION BY THE PARENT/LEGAL GUARDIAN OF

I consent to my child being administered the prescribed medicine as detailed in Section 3 in accordance with the dosage at the following time(s)

  1. between 8.30 am and 12.00 pm at __________________________________________

 

  1. between 12.00 pm and 4.00 pm at __________________________________________

 

I understand that the LA, Governing Body of the school and the staff cannot accept responsibility for any adverse reaction my child may suffer as a consequence of being administered the prescribed medication at my request.

Signed _____________________________________________

Relationship to child: _________________________________

Date:

 

SECTION 7

APPROVAL FOR REQUEST             YES / NO

_______________________________          Headteacher

_______________________________          Date