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Chalkwell Hall

Infant School

Medical Form

Please note this is only a test

 

 

Instructions: Please copy text below and paste into a blank email. Fill in the boxes then send your email to david.horne@chalkwellhallinfants.co.uk

 

Parental agreement for Chalkwell Hall Infant School to administer medication

 

Chalkwell Hall Infant School will not give your child medication unless you complete and sign this form.  This school has a policy that the staff can volunteer to administer medicine.  (Medical Conditions Policy)

 

Name of School

Chalkwell Hall Infant School

Name of child

 

Date of birth

 

Class

 

Medical condition or illness


 

Name of person bringing medicine in to school

 

Date medication was brought into school

 
   

Medicine

Name/type/form of medicine

(as described on the container)

 

Medication amount supplied

 

Date dispensed (prescription only medication)

 

Expiry date

 

Agreed review date to be initiated by

Emma Howe

Dosage and method regime

 

Has a dose already been given today? If so, what time was this?

(Please be aware you will need to notify the

school of each dose given at home prior to the

start of the school day. Without this information,

the school will be unable to administer your child’s medication).

 

Times medication to be administered 

 

Dates medicine is to be taken 

 

Does medication need to be taken at After School Club?

If so, please state the dosage amount and time medication is to be administered.

 

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

 

Is your child on any other medication?

If so, please state what medication

 

Self-administration

Yes/No

Procedures to take in an emergency 

 
 

Contact Details

 

Name

                     

Daytime telephone no

   

Relationship to child

   

Address

   
 

I understand that I must personally deliver the medicine to the Infant School Office.

I understand that this is a service that the school is not obliged to undertake.

I understand that I must notify the school of any changes in writing.

I understand that I must collect all medicine when it expires and/or at the end of the school day/year.

 

Signed: _____________________________________ Date:___________________________

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