Home Page

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


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




Medical condition or illness


Name of person bringing medicine in to school


Date medication was brought into school



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




Procedures to take in an emergency 


Contact Details




Daytime telephone no


Relationship to child




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:___________________________