Medical Agreement Form

Parental Agreement For Hilltop School
To Administer Medicine

We cannot give your child medicine unless you complete and sign this form.

* Indicates required field

Date *

Child's Name *

First

Last

Class *

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? *

Was There Any Adverse Reaction To The Medication? *

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

• Only students that have had permission from parents / carers can have their image shown on our website •

For information, advice & to report concerns directly to CEOP, visit the Safety Centre

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• Paper copies of information on our school website are available from our school office •

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Maltby Hilltop School; an Academy in Nexus Multi Academy Trust; A Private Ltd Company;
Registered in England & Wales Company Number: 10075893
Registered Office: Maltby Hilltop School, Larch Road, Maltby, Rotherham, S. Yorks, England, S66 8AZ
A charitable company. www.nexusmat.org

Parental Agreement For Hilltop SchoolTo Administer Medicine

We cannot give your child medicine unless you complete and sign this form.

​​​​​​​﻿• Only students that have had permission from parents / carers can have their image shown on our website •