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Parent View
Parental Agreement For Hilltop School
To Administer Medicine
* A paper copy of this form can be requested from the school office *
We cannot give your child medicine unless you complete and sign this form.
*
Indicates required field
Date
*
Child's Name
*
First
Last
Class
*
Please Use Dropdown Box
Orange
Yellow
Blossom
Larch
Silver
Pink
Green
Blue
Red
Lime
Jade
Rainbow
Purple
Gold
Indigo
Upper 1
Upper 2
Homebase 1 & 2
Homebase 3
Name & Strength of Medicine
*
Expiry Date
*
How Much To Give (i.e. Dose To Be Given)
*
When To Be Given?
*
Any Other Instructions
*
Have They Had The Medicine Before?
*
Please Use Dropdown Box
No
Yes
Was There Any Adverse Reaction To The Medication?
*
Please Use Dropdown Box
No
Yes
If YES Please Give Details
*
Note: Medicine must be in the original container as dispensed by the pharmacy with a clear label,in date with your
child’s name
Daytime Phone No. of Parents or Carer Contact
*
Name & Phone No. of GP
*
Agreed Start Date of Medication With School
*
The above information is, to the best of my knowledge, accurate at the time of writing.
By completing this form, I give consent to Hilltop school staff administering medicine.
If there is any change in dosage /frequency or the medication has stopped, I will inform school immediately.
Parent / Carer's Name
*
First
Last
E-mail
*
Note: If your child comes to school on transport, can you make sure you hand over & receive medication from the escort.
If more than one medicine is to be given, a separate form must be completed for each one.
Submit